RU2724276C1 - Method for rapid assessment of axial skeleton involvement risk in early forms of psoriatic arthritis - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to rheumatology. Level of C-reactive protein (CRP), presence of HLA-B27 antigen, area of skin lesion BSA, activity of peripheral arthritis by DAS index, patient's sex are determined. Based on the obtained information, calculating Y is calculated by formula: Y=1.566*X1+0.957*X2+0.986*X1+1.845*X4+0.6*X5, where: X1 – level of C-reactive protein (mg/l), if CRP more than 5 mg/l, then assign 1 point, if CRP 5 mg/l and less, then assign 0 points; X2 – presence of HLA-B27 antigen, if HLA-B27 is detected, then 1 point is assigned, if not detected – 0 points; X3 is BSA skin lesion area, if BSA is more than 3 %, then 1 point is assigned; if 3 % and less is 0 points; X4 – peripheral arthritis activity by DAS index, if activity by DAS is moderate or high, then 1 point is assigned; if low or remission is 0 points; X5 is the sex of the patient, if male, then 1 point is assigned, if female – 0 points. If Y is more than 3.75, presence of high risk of axial skeleton lesion in early forms of psoriatic arthritis (PsA) is determined.EFFECT: method enables detecting a high risk of axial skeleton damage in early forms of PsA in rapid mode, which in turn enables prescribing an individual therapy adequate to the clinical situation.1 cl, 2 ex

Description

FIELD OF THE INVENTION

The invention relates to medicine, namely to rheumatology, and can be used for screening axial lesions in patients with early forms of psoriatic arthritis (PsA).

State of the art

The frequency of axial lesions in PsA, according to various authors, varies from 25 to 70% [Fernandez-Sueiro J. L. The Challenge and Need of Defining Axial Psoriatic Arthritis J Rheumatol 2009; 36; 2633-2634 doi: 10.3899 / jrheum.091023. Mease PJ, Palmer JB, Liu M, 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 doi: 10.3899 / jrheum.171094]. Such a wide range of data is due to the fact that, until now, a single approach to the diagnosis of axial PsA has not been formed. Inadequate diagnosis of axial skeleton damage is an unresolved problem not only in the Russian Federation, but also in the world rheumatology community.

Inadequate and late diagnosis of damage to the axial skeleton due to the following factors:

возможностью субклинического (безболевого) течения аксиального поражения [Aydin SZ, Kucuksahin О Kilic L. et al. Axial psoriatic arthritis: the impact of underdiagnosed disease on outcomes in real life. Clinical Rheumatology 2018;37: 3343-8 https://doi.org/10.1007/s10067-018-4173-4]

the possibility of a subclinical (painless) course of axial damage [Aydin SZ, Kucuksahin About Kilic L. et al. Axial psoriatic arthritis: the impact of underdiagnosed disease on outcomes in real life. Clinical Rheumatology 2018; 37: 3343-8 https://doi.org/10.1007/s10067-018-4173-4]

отсутствием четких критериев диагноза «аксиальный ПсА» [Mease PJ, Palmer JB, Liu M, 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 doi:10.3899/jrheum.171094]

the lack of clear criteria for the diagnosis of axial PsA [Mease PJ, Palmer JB, Liu M, 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 doi: 10.3899 / jrheum.171094]

низкой осведомленностью врачей

low awareness of doctors

отсутствием простых и доступных методов скрининга в реальной клинической практике.

lack of simple and affordable screening methods in real clinical practice.

It should be noted the high social significance of this problem. Axial damage is often found in young men of working age and significantly reduces their ability to work.

Currently, there is evidence of a more severe course of PsA if the axial skeleton is involved in the inflammatory process, compared with purely peripheral forms of the disease [Mease PJ, Palmer JB, Liu M, 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 doi: 10.3899 / jrheum.171094. Gubar EE, Loginova EU, Smirnov AB, etc. Clinical and instrumental characteristics of axial lesion in early peripheral psoriatic arthritis. (REMARK study data). Scientific and practical rheumatology 2018; 56 (1): 34-40], which indicates the need for rheumatologists to actively identify axial forms of PsA.

It is especially important that, according to international recommendations for the treatment of PsA [Nash P, Lubrano E, Cauli A, et al. Updated Guidelines for the Management of Axial Disease in Psoriatic Arthritis. J Rheumatol. 2014 Nov; 41 (11): 2286-9. doi: 10.3899 / jrheum. 140877. van der Heijde D, Ramiro S, Landewe R, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis 2017; 76: 978-991. doi: 10.1136 / annrheumdis-2016-210770. Singh JA, Guyatt G, Ogdie A. et al. 2018 American College of Rheumatology / National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis. Arthritis Care & Research Vol. 0, No. 0, 2018, pp 1-28 doi 10.1002 / acr.23789], the presence of an axial lesion in a patient is of independent importance for the choice of therapy. Thus, a delay in the diagnosis of damage to the axial skeleton in early forms of PsA is highly undesirable.

Diagnosis of axial damage in PsA is a whole complex of examinations: targeted detection of inflammatory back pain (CHD) in a patient and visualization of axial structures.

ASAS is used to detect CHD [Sieper J, van der Heijde DM, Landewe 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 (6): 784-8 doi: 10.1136 / ard.2008.101501]. However, it should be noted that in 25% of PsA patients with axial skeleton lesions, there is no CHD [Jadon D.R, Sengupta R, Nightingale A. et al. Axial Disease in Psoriatic Arthritis study: defining the clinical and radiographic phenotype of psoriatic spondyloarthritis. Ann Rheum Dis 2016; 0: 1 -7. doi: 10.1136 / annrheumdis-2016-209853; Gubar EE, Loginova EU, Smirnov AB, etc. Clinical and instrumental characteristics of axial damage in early peripheral psoriatic arthritis. (REMARK study data). Scientific and Practical Rheumatology 2018; 56 (1): 34-40]. Among PsA patients in whom CHD was detected, in more than half of cases (55.6% - 60.3% according to our data), these pains are episodic and mild [Gubar EE, Loginova EU, Korotaeva T.V. et al. Comparative characteristics of early psoriatic arthritis with and without lesion of the axial skeleton (subanalysis of the all-Russian register of patients with psoriatic arthritis). Scientific and practical rheumatology 2019; 57 (6): 636-641 https://doi.org/10.14412/1995-4484-2019-636-641] and often their only localization is the cervical spine. Patients do not always actively inform the doctor about the presence of similar pains in their neck / back [Gubar EE, Loginova EU, Korotaeva T.V. et al. Comparative characteristics of early psoriatic arthritis with and without lesion of the axial skeleton (subanalysis of the all-Russian register of patients with psoriatic arthritis). Scientific and Practical Rheumatology 2019; 57 (6): 636-641 https://doi.org/10.14412/1995-4484-2019-636-641]. Axial PsA criteria for axial PsA are “not met” in all patients, but only for high disease activity (back pain ≥4, BASDAI indicators ≥4) [Haroon M, Gallagher P, FitzGerald O. Inflammatory back pain criteria perform well in subset of patients with active axial psoriatic arthritis but not among patients with established axial disease. Ann Rheum Dis. 2019; 78 (7): 1003-1004. doi: 10.1136 / annrheumdis-2018-214583.] Due to the above factors, the sensitivity of the ASR questionnaire (ASAS) is lower for axial PsA than for ankylosing spondylitis (AC). [Aydin SZ, Kilic L, Kucuksahin O. et al. Performances of inflammatory back pain criteria in axial psoriatic arthritis. Rheumatology (Oxford) 2017; 56 (11): 2031-2032. doi: 10.1093 / rheumatology / kex307]. He accidentally, when examining large cohorts of patients with PsA, PFS was detected in only 15% of cases [Baraliakos X, Coates LC, Braun J. The involvement of the spine in psoriatic arthritis. Clin Exp Rheumatol. 2015; 33 (Suppl 93): S31-5.]. Due to the characteristic feature of axial PsA - the possibility of a painless course of axial damage - existing diagnostic methods cannot be fully applied.

Due to the fact that no consensus has yet been reached regarding the criteria for the diagnosis of axial PsA, various studies use different imaging methods to confirm axial skeletal damage: the most commonly used is the X-ray of the sacroiliac joints (CPS) [Aydin SZ, Kilic L, Kucuksahin, O. et al. Performances of inflammatory back pain criteria in axial psoriatic arthritis. Rheumatology (Oxford) 2017; 56 (11): 2031-2032. doi: 10.1093 / rheumatology / kex307], less commonly the cervical and lumbar spine [Jadon D.R., Sengupta R, Nightingale A. et al. Axial Disease in Psoriatic Arthritis study: defining the clinical and radiographic phenotype of psoriatic spondyloarthritis. Ann Rheum Dis 2016; 0: 1 -7. doi: 10.1136 / annrheumdis-2016-209853], in some works with early forms of the PsA-magnetic resonance (MRI) examination of the CPS [Gubar EE, Loginova EU, Smirnov AB et al. Clinical and instrumental characteristics of axial lesion in early peripheral psoriatic arthritis . (REMARK study data). Scientific and Practical Rheumatology 2018; 56 (1): 34-40]. Most authors [Aydin SZ, Kilic L, Kucuksahin O. et al. Performances of inflammatory back pain criteria in axial psoriatic arthritis. Rheumatology (Oxford) 2017; 56 (11): 2031-2032. doi: 10.1093 / rheumatology / kex307.] Most authors diagnose axial damage if the patient has radiologically significant sacroiliitis (SI), ie meeting the modified New York criteria (bilateral ≥II st. or unilateral ≥III st.) [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 (4): 361-8.], Although in some works the presence of even one-sided SI II art [Haroon M, Winchester R, Giles JT. et al. Clinical and genetic associations of radiographic sacroiliitis and its different patterns in psoriatic arthritis. Clin Exp Rheumatol. 2017; 35 (2): 270-276].

It should be noted that significant structural (radiological) changes in the CPS are not formed at the initial stages of the disease. Among our patients with early forms of PsA, which had an axial lesion, radiologically significant SI was detected in 44.6% of cases [Gubar EE, Loginova EE, Korotaeva T.V. et al. Comparative characteristics of early psoriatic arthritis with and without lesion of the axial skeleton (subanalysis of the all-Russian register of patients with psoriatic arthritis). Scientific and Practical Rheumatology 2019; 57 (6): 636-641 https://doi.org/10.14412/1995-4484-2019-636-641]. In addition, the interpretation of x-ray changes corresponding to the early stages of SI (art. II) often causes difficulties, due to the anatomical features of the CPS [Wanders, AJ, Landewe, RB, Spoorenberg, A., Dougados, M., van der Linden, S., Mielants, H .. (2004) What is the most appropriate radiologic scoring method for ankylosing spondylitis? A comparison of the available methods based on the Outcome Measures in Rheumatology Clinical Trials filter. Arthritis Rheum 50: 2622-2632.] And requires special qualifications of an expert radiologist. It should also be borne in mind that with PsA, unlike AS, a spine lesion is possible without SI [Jadon D.R, Sengupta R, Nightingale A. et al. Axial Disease in Psoriatic Arthritis study: defining the clinical and radiographic phenotype of psoriatic spondylarthritis. Ann Rheum Dis 2016; 0: 1-7. doi: 10.1136 / annrheumdis-2016-209853], according to Jadon et al. up to 33% of cases, which requires additional radiography and / or MRI of the cervical and lumbar spine.

When radiography of the cervical and lumbar spine, axial damage is established in the presence of at least one syndesmophyte / parasindesmofit [Jadon D. R, Sengupta R, Nightingale A. et al. Axial Disease in Psoriatic Arthritis study: defining the clinical and radiographic phenotype of psoriatic spondyloarthritis. Ann Rheum Dis 2016; 0: 1 -7. doi: 10.1136 / annrheumdis-2016-209853]. At the same time, it should be noted that narrowing and ankylosis of the arched joints (damage to the posterior sections), especially in the cervical spine, occurs in 28% of PsA patients [Laiho K, Kauppi M The cervical spine in patients with psoriatic arthritis. Ann Rheum Dis. 2002 Jul; 61 (7): 650-652. doi: 10.1136 / ard.61.7.650]. Damage to the posterior spine can be detected in patients who do not have syndesmophytes, but, nevertheless, also indicates damage to the axial skeleton in PsA.

Regarding the possibility of detecting active inflammation (osteitis) of CPS according to MRI in PsA patients, it should be noted that this symptom is not observed in all patients with axial damage and not at all stages of the disease. According to MRI data, active SI was diagnosed by us in 43.07% of patients who had an axial lesion in early forms of PsA [Gubar EE, Loginova EU, Korotaeva T.V. et al. Comparative characteristics of early psoriatic arthritis with and without lesion of the axial skeleton (subanalysis of the all-Russian register of patients with psoriatic arthritis). Scientific and Practical Rheumatology 2019; 57 (6): 636-641 https://doi.org/10.14412/1995-4484-2019-636-641]. According to Williamson et al. [Williamson L, Dockerty JL, Dalbeth N Clinical assessment of sacroiliitis and HLA-B27 are poor predictors of sacroiliitis diagnosed by magnetic resonance imaging in psoriatic arthritis. Rheumatology (Oxford). 2004 Jan; 43 (l): 85-8] the presence of symptoms of MI on MRI did not correlate with the presence of CHD in patients.

All of the above factors indicate the complexity and complex nature of the diagnosis of axial damage in PsA. Existing imaging methods require the involvement of specially trained radiologists and expensive MRI equipment, which can be difficult to implement in clinical practice, especially in remote regions. The introduction of clinical screening into clinical practice - to identify patients with a high risk of axial skeleton damage - will avoid the use of complex and costly examinations, shorten the examination time and will facilitate the timely appointment of adequate therapy. At present, there are no objective methods of screening and diagnostics that reveal a high risk of axial skeleton damage in early forms of PsA.

Disclosure of invention

The technical problem to be solved and the technical result achieved was the identification in the express mode of a high risk of axial skeleton damage in early forms of PsA, which in turn allows us to prescribe individual therapy adequate to the clinical situation in a timely manner.

As part of the study, we identified a set of prognostically significant indicators, and also obtained the following discriminant classification rule associated with axial PsA:

Y = 1.566 * X1 + 0.957 * X2 + 0.986 * X3 + 1.845 * X4 + 0.6 * X5,

where: X1 - level of C-reactive protein (mg / l), if CRP is more than 5 mg / l, assign “1 point”, if CRP is 5 mg / l or less - “0 points”;

X2 - the presence of HLA-B27 antigen, if HLA-B27 is detected, assign "1 point", if not detected - "0 points";

X3 - area of skin lesion of BSA, if BSA is more than 3%, assign "1 point", if 3% or less - "0 points";

X4 - peripheral arthritis activity according to the DAS index, if the DAS activity is moderate or high, assign “1 point”, if low or remission - “0 points”;

X5 - gender of the patient, if male, assign “1 point”, if female - “0 points”, with a value of Y more than 3.75, determine the presence of a high risk of damage to the axial skeleton in early forms of PsA.

The sensitivity of the model was 68%, specificity - 73%.

We examined 95 patients: 47 men and 48 women with a diagnosis of PsA that met the criteria of CASPAR (2006). The average age of patients was 36.5 ± 10.7 years, the duration of peripheral arthritis was 12.2 ± 10.3 months. Patients with back / neck pain or with limited mobility of the spine were not specifically selected. All patients underwent a standard clinical examination of PsA. Peripheral arthritis activity was assessed by the DAS index. DAS> 3.7 corresponds to a high activity of the disease, 2.4 ≤DAS≤3.7 - moderate activity; 1.6 ≤ DAS <2.4 - low activity, DAS <1.6 - remission.

In a targeted survey, all patients were evaluated for CHD according to ASAS criteria [Sieper J, van der Heijde DM, Landewe 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 (6): 784-8]. PBC was qualified as permanent or episodic. Episodic was considered pain lasting, in general, more than three months, but having an unstable character. In patients reporting episodic neck / back pain, an assessment of CHD was performed when this pain appeared. Despite the episodic nature of the pain, during exacerbations there were all signs of CHD according to ASAS criteria [Sieper J, van der Heijde DM, Landewe 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 (6): 784-8].

All patients underwent standard pelvic radiography. X-ray during radiography (RSI) was diagnosed in the presence of changes that meet the modified New York criteria (bilateral II st. And higher or unilateral III st. And higher according to Kellgren).

79 patients, regardless of their presence of CHD, were additionally underwent MRI CPS on a low-floor Signa Ovation 0.35T device. Active SR with MRI (MRI-SR) in the STIR mode was diagnosed in the presence of a bone marrow edema (OKM) zone in KPS, at least on two consecutive sections, or in the presence of 2 or more zones of OKM, on one section [Rudwaleit M, Jurik AG, Hermann K-GA, et al. Defining active sacroiliitis on magnetic resonance imaging (MRI) for classification of axial spondyloarthritis: a consensual approach by the ASAS / OMERACT MRI group.Ann Rheum Dis. 2009; 68: 1520-7]. Radiography and MPT results were evaluated by an independent, specially trained radiologist expert.

93 patients underwent serological typing of HLA-B27 antigen by polymerase chain reaction. The area of skin lesion was estimated by BSA (Body Surface Area). With involvement <3%, it was considered insignificant, 3% -10% moderate and> 10% widespread. When determining BSA, it was believed that 1 palm of the patient to the middle phalanges of the fingers corresponds to 1% of the body area.

CHD was detected in 63 (66.3%) patients, and in 35 (55.6%) of them it was of an unstable, episodic nature; MRI-SI was detected in 28 of 79 (35.4%) examined patients, RSI was diagnosed in 29 (30.5%) patients.

The clinical features of two groups of patients with early PsA were compared: with the involvement of the axial skeleton (axPsA) and without axial damage (only peripheral PsA - pPSA).

The ACPSA group included patients with CHD and / or RSI and / or MRI-SI. The acPSA group included 65 (68.4%) patients, the pPSA group included 30 (31.6%) patients.

Among the patients with APSA there were significantly more males than in the PPSA group - 39 (60%) and 8 (26.7%), respectively (p = 0.003).

The HLA-B27 antigen was detected significantly more often in patients with axPsA than in the group of pPSA patients - in 30 (47.6%) and 7 (23.3%), respectively (p = 0.02).

In patients with axPSA, peripheral arthritis activity was significantly higher.

High activity of peripheral arthritis by the DAS index was observed in 49 (73.1%) patients with APSA and in 13 (48.2%) patients with APSA (p = 0.021). Moderate and high DAS activity was present in 64 (98.5%) patients from the APSA group and in 22 (73.3%) patients with APSA (p = 0.015)

CRP level exceeded 5 mg / L significantly more often in patients with APSA than in patients with APSA - in 58 of 65 (89.3%) and 19 of 30 (63.3%), respectively (OR 4.80 [95% CI 1.63-14.13] p = 0.004)

The area of skin lesion BSA> 3% was detected more often in patients with axPSA than in the group of patients with pPSA in 24 of 59 (40.7%) and 4 of 27 (14, 8%), respectively (OR 3.94 [95 % CI 1.21-12.86] p = 0.023).

The combination of such signs as male gender, the presence of HLA-B27 antigen, high or moderate activity of peripheral arthritis by the DAS index, CRP> 5 mg / l, the area of skin lesion - BSA> 3% was prognostically significant for diagnosis, involvement in the inflammatory process of axial skeleton with psa.

There were other significant differences between the groups of APSA and pPSA: the age of patients with APSA was younger, the duration of arthritis in these patients was less, the indicators of subjective assessment of patients (general assessment of the patient’s disease, assessment of patient pain) with APSA were significantly worse than with PPSA. But these signs when using multidimensional stepwise discriminant analysis were not prognostically significant for the diagnosis of axial damage.

The method is as follows.

Determine the level of CRP, the presence of HLA-B 27 antigen, the area of skin lesion BSA, the activity of peripheral arthritis by the DAS index, the gender of the patient. Based on the information received, calculate the indicator U by the formula:

Y = 1.566 * X1 + 0.957 * X2 + 0.986 * X3 + 1.845 * X4 + 0.6 * X5,

where: X1 - level of C-reactive protein (mg / l), if CRP is more than 5 mg / l, then assign “1 point”, if CRP is 5 mg / l or less, then assign “0 points”;

X2 - the presence of HLA-B27 antigen, if HLA-B27 is detected, assign "1 point", if not detected - "0 points";

X3 - area of skin lesion of BSA, if BSA is more than 3%, assign "1 point", if 3% or less - "0 points";

X4 - peripheral arthritis activity according to the DAS index, if the DAS activity is moderate or high, assign “1 point”, if low or remission - “0 points”;

X5 - gender of the patient, if male, then assign “1 point”, if female - “0 points”.

With a value of Y more than 3.75, determine the presence of a high risk of damage to the axial skeleton in early forms of PsA.

Example No. 1

Patient Sh., A man, 32 years old, was admitted to the 2nd rheumatology department of the Federal State Budget Scientific Institution NIIR named after V.A. Nasonova in January 2018 with complaints of pain and swelling in the left wrist, right knee and right ankle joints, joints of the hands and feet, pain in the lumbosacral spine of an inflammatory nature, for common skin rashes accompanied by itching, fever up to 39 ° C. Common psoriasis for 15 years. The duration of peripheral arthritis is 1 year. Episodic pains in the cervical spine for 6 years, in the lumbosacral - 4 years, persistent inflammatory pain in the lumbosacral (ASAS criteria) - 8 months. On examination: common plaque psoriasis, BSA - 60%, PASI - 40.3; psoriatic onychodystrophy (all nail plates are affected), polyarthritis, acute dactylitis of the third toe of the right foot and the first toe of the left foot, LEI (Leeds Enthestis Index) - 4. The patient had a decrease in rotation in the cervical spine - 35/40 degrees. High activity of peripheral arthritis and spondylitis was found for all the studied indices: DAPSA (Disease Activity In Psoriatic Arthritis) = 70.7; BASDAI (Bath Ankilosing Spondylitis Disease Activity Index) = 7.0; ASDASCPB (Ankylosing Spondylitis Disease Activity Score,) = 5.3; DAS = 4.7. High acute phase inflammation indicators were noted: ESR - 62 mm / hour (according to Panchenkov), highly sensitive CRP (hsCRP) - 122 mg / l (high CRP for 4 years). The HLA-B27 antigen was detected. Rheumatoid factor <10.6 IU / ml. According to the X-ray of the pelvis revealed bilateral sacroiliitis 2 stages - on the right, 3 stages - on the left according to Kellgren. According to the radiography of the cervical spine: the emerging syndesmophyte C6-C7. There were radiographic signs of erosive arthritis of the distal feet with osteolysis in 5 PMPS on the right and 3 PMPS on the left, periarticular bone proliferation in 1 interphalangeal joint of the right foot and 2 DMPS of the left foot. MRI of the CPS was not performed.

Thus, the diagnosis of PsA in the patient meets the CASPAR criteria: the presence of psoriasis at the time of examination, psoriatic dystrophy of the nails, dactylitis at the time of examination, negative rheumatoid factor, extra-articular bone proliferation according to the type of marginal growths on radiographs of the feet.

The presence of inflammatory back pain in the patient (ASAS criteria), the detection by radiography of radiologically-valid SI II-III art according to Kelgren indicates in favor of axial damage. A feature of axial damage in PsA is involvement in the inflammatory process of the cervical spine: limiting cervical rotation to 35/40 degrees, the formation of syndesmophyte in the cervical spine between C6-C7.

The axial lesion in patient C. could be established on a screening prior to hospitalization, without instrumental examination and at the stage when the pain in the back and neck was still episodic. Patient S. has a combination of the following indicators: male gender, the presence of HLA-B27 antigen, high activity of peripheral arthritis according to DAS, area of skin lesion BSA> 3%, CRP> 5 mg / L.

Based on the data obtained, the Y index was calculated according to the original formula:

Y = 1.566 * X1 + 0.957 * X2 + 0.986 * X3 + 1.845 * X4 + 0.6 * X5 = 1.566 * 1 + 0.957 * 1 + 0.986 * 1 + 1.845 * 1 + 0.6 * 1 = 5.954

Thus, patient Sh. Has a high risk of axial skeleton damage in early forms of PsA.

An early detection of axial damage in this case would contribute to an earlier appointment of genetic engineering biological therapy (GIBT), since the use of synthetic basic anti-inflammatory drugs for damage to the axial skeleton is ineffective. However, patient Sh. Was prescribed methotrexate, leflunomide, hormone therapy (metipred), various non-steroidal anti-inflammatory drugs (NSAIDs) at the place of residence. Therapy was ineffective, in addition, the patient had intolerance to many drugs. Patient C. also had a serious concomitant disease - chronic viral hepatitis C (RNA-negative).

Due to the presence of axial skeletal lesions in the patient, high disease activity, the patient was shown GIBT: the use of TNF-alpha inhibitors, or an interleukin 17A inhibitor (IL-17A). In the clinic, FSBI NIIR them. V.A. An nasal patient (taking into account a chronic infection of viral hepatitis C and severe psoriasis) was assigned an IL-17A inhibitor - secukinumab (Cosentix). High efficacy of therapy was noted in relation to all symptoms of PsA, including spondylitis, and a quick response to therapy.

Example No. 2

Patient M., a man, 53 years old, was admitted to the 2nd rheumatology department of the Federal State Budget Scientific Institution NIIR named after V.A. Nasonova in September 2016 with complaints of recurrent inflammatory pain (ASAS criteria) in the lower back and cervical spine, pain and swelling in the right ankle, in the right Shoparov joints, pain and swelling in some joints of the hands and feet, swelling II toe of the right foot. The duration of arthritis is 2 years. Periodic inflammatory pain in the lower back and in the cervical spine for about 23 years. Was observed with a diagnosis of osteochondrosis, disc herniation, received various NSAIDs - with a temporary effect. Psoriasis for 24 years (inverse psoriasis). On examination, psoriasis is inverse with damage to the inguinal region, interalogal folds, BSA - 1%, psoriatic onychodystrophy; oligoarthritis, acute dactylitis of the second toe of the right foot, limited movement in the cervical spine (rotation 40/45 degrees), a slight restriction in the lumbar (Schober symptom 4 cm). ESR - 35 mm / h, hsCPB - 38.9 mg / l. High disease activity according to BASDAI indices = 4.1; DAPSA = 31.09; DAS = 4.4.

Examination revealed the HLA-B27 antigen, according to pelvic radiography, bilateral sacroiliitis of the II degree, gross syndesmophytes and parasindesmophytes in the cervical (C5-C6) and lower thoracic and lumbar regions (Th9-Th10, Th11-Th12, L3-L4, L4-L5 ) of the spine, narrowing of the arched joints in the cervical region with ankylosis C2-C3. According to the radiography of the feet: extra-articular erosion, partial ankylosis of the I metatarsophalangeal joint. According to MRI, KPS is a bilateral chronic erosive SI without signs of active inflammation. Thus, the diagnosis of PsA in a patient meets the CASPAR criteria: the presence of psoriasis at the time of examination, psoriatic dystrophy of the nails, dactylitis at the time of examination.

The patient has an axial lesion: recurrent inflammatory pain in the lower back and in the cervical spine (ASAS criteria), radiographic recognition of radiographically reliable SI - two-sided SI II art. Kellgren, syndesmophytes and parasindesmophytes in the cervical and lower thoracic spine . A characteristic feature of psoriatic spondylitis in patient M. is the non-constant, periodic nature of inflammatory back pain, the presence of gross, voluminous, asymmetric syndesmophytes and parasindesmophytes, an unexpanded stage of sacroiliitis (II grade) over 23 years of axial damage, involvement of the cervical spine with posterior lesions departments (ankylosis of the arched joints).

Patient M. has a combination of the following indicators: male gender, the presence of HLA-B27 antigen, high activity of peripheral arthritis by DAS, CRP> 5 mg / L. Patient M. does not have severe psoriasis, area of skin lesion BSA <3%

Based on the data obtained, the Y index was calculated according to the original formula:

Y = 1.566 * X1 + 0.957 * X2 + 0.986 * X3 + 1.845 * X4 + 0.6 * X5 = 1.566 * 1 + 0.957 * 1 + 0.986 * 0 + 1.845 * 1 + 0.6 * 1 = 4.968

Thus, patient M. has a high risk of damage to the axial skeleton in early forms of PsA.

In this case, early detection during axial lesion screening would contribute to the correct diagnosis and the appointment of adequate therapy. The patient was observed for a long time with a diagnosis of osteochondrosis, took only NSAIDs. After the development of peripheral arthritis in a patient, sulfasalazine was added to the therapy without any definite effect. Due to the patient’s lack of disability, genetic engineering biological therapy was not initiated. In the hospital, methotrexate therapy (Metoject) 15 mg per week was started. The use of methotrexate - with an incomplete effect against arthritis and dactylitis, against spondylitis - without effect.

However, taking into account the revealed axial lesion, the patient subsequently began to take tofacitinib (Yakvinus) 10 mg / day in combination with meloxicam 15 mg / day, this treatment regimen was effective.

Presented clinical examples indicate the following factors:

1. In rheumatological practice, there is a delay in the diagnosis of axial damage in PsA.

2. The original formula we obtained for identifying a high risk of axial skeleton damage in early forms of PsA, taking into account a set of prognostically significant indicators, has shown its effectiveness in practice.

3. The use of this mathematical method in the early stages of the disease will contribute to the earlier start of adequate therapy.

4. If a high risk of axial damage is detected in patients with early forms of PsA, these patients should be examined using radiography and MRI. In this way, costly expenses will be optimized.

Claims (7)

A method for the rapid assessment of the risk of damage to the axial skeleton in early forms of psoriatic arthritis, including determining the level of CRP, area of skin lesion of BSA, patient gender, the presence of HLA-B27 antigen, activity of peripheral arthritis by the DAS index, based on the obtained information, the Y indicator is calculated: Y = 1.566 * X1 + 0.957 * X2 + 0.986 * X3 + 1.845 * X4 + 0.6 * X5, where: X1 is the level of C-reactive protein (mg / l), if CRP is more than 5 mg / l, then 1 point is assigned, if CRP is 5 mg / l or less, then 0 points are assigned; X2 - the presence of HLA-B27 antigen, if detected HLA-B27, then assign 1 point, if not detected - 0 points; X3 - area of skin lesion of BSA, if BSA is more than 3%, then assign 1 point, if 3% or less - 0 points; X4 - activity of peripheral arthritis according to the DAS index, if the activity according to DAS is moderate or high, then assign 1 point, if low or remission - 0 points; X5 - gender of the patient, if male, then assign 1 point, if female - 0 points, with a value of Y more than 3.75 determine the presence of a high risk of damage to the axial skeleton in early forms of PsA.