1. Psoriatic Arthritis and Diet:an Individualized ApproachDr. Alexander Shikhman MD, PhD, FACRInstitute for Specialized Medicine www.ifsmed.com

2. Psoriatic Arthritis Inflammatory joint disease found in up to 30% ofpatients with psoriasis Stiffness, pain, swelling and tenderness of the jointsand surrounding ligaments and tendons Early recognition, diagnosis and treatment can helpprevent progressive joint involvement and damage Skin symptoms usually appear before joint symptoms, but not always 3. Psoriatic ArthritisSymptoms to be aware of: Back pain/stiffness Pain in heel or bottom of foot Morning stiffness lasting longer than 30minutes Generalized fatigue Reduced range of motion Swollen fingers and/or toes 4. Psoriatic ArthritisIf you have psoriasis and are experiencing any symptomsof psoriatic arthritis, it is a good idea to: Tell your health care provider Consider seeing a rheumatologist Not wait for your symptoms to get worse before seekingmedical advice and/or treatment 5. Psoriatic Arthritis is a Part ofSpondyloarthropathies Ankylosing Spondylitis Reactive arthritis (Reiters syndrome) Enteropathic spondylitis or spondylitis associated withinflammatory bowel disease (including Crohns diseaseand ulcerative colitis) Psoriatic arthritis Isolated acute anterior uveitis Undifferentiated spondyloarthropathy (USpA) 6. Psoriatic Arthritis is a Part of SpondyloarthropathiesThe hallmark of thespondyloarthropathies, includingpsoriatic arthritis, is theinflammatory process affectingthe junction betweenligaments/tendons and theanchor bone called enthesitis 7. Genetics of Psoriatic ArthritisHigh prevalence of:HLA B27 (subtypes B*2701-2759)HLA DQ8.1 (DQA1*0301:DQB1*0302) 8. Diagnosing Psoriatic Arthritis There is no single test to diagnose psoriatic arthritisTypically, the diagnosis of psoriatic arthritis is based on acombination of: Patients history Physical examination Imaging of the joints (x-rays, ultrasound, MRI etc) Laboratory test results 9. Subtypes of Psoriatic Arthritis Asymmetrical mono- andoligoarticular arthritis (30-50% ofcases) is the most commonpresentation of psoriatic arthritis Dactylitis presents as the so-called "sausage digit", diffuseswelling of the entire digit likelydue to a combination of botharthritis and tenosynovitis 10. Subtypes of Psoriatic ArthritisSymmetrical polyarticular arthritis(20-40% of cases) is the secondmost common form of psoriaticarthritis 11. Subtypes of Psoriatic Arthritis Distal interphalangeal (DIP) jointinvolvement (20-30% of cases) isnearly always associated with nailmanifestations Nail involvement may be manifestedas pitting, ridging, separation from thenail bed (onycholysis) or yellow-orangediscoloration ("oil drop" sign) 12. Subtypes of Psoriatic Arthritis Axial arthritis (20-30% of cases) maybe different in character fromankylosing spondylitis, theprototypical HLA-B27-associatedspondyloarthropathy It may present as sacro-iliitis, whichmay be asymmetrical andasymptomatic, or spondylitis, whichmay occur without sacro-iliitis andmay affect any level of the spine in"skip" fashion 13. Subtypes of Psoriatic Arthritis Arthritis mutilans (5% of cases)is characterized by resorptionof the phalangeal bones 14. Psoriatic Arthritis: Satellite Problems Extra-Cutaneous andOverlapping ProblemsArticular Manifestations Conjunctivitis Gout UveitisPseudogout (calcium pyrophosphate deposition Aortitis (inflammation of aorta) disease) Pulmonary fibrosis 15. Psoriasis, Psoriatic Arthritis and InfectionTHE FOLLOWING INFECTIOUS AGENTS HAVE BEEN ASSOCIATED WITH ACTIVATION OF PSORIASIS AND PSORIATIC ARTHRITIS Streptococcus pyogenes group A Candida albicans Helicobacter pylori Atypical mycobacteria Mycoplasma pneumonia Human immunodeficiency virus (HIV) Hepatitis C 16. Psoriasis, Psoriatic Arthritis andStreptococcal Infection Early studies on T cells in the skin revealed the presence ofoligoclonal T-cells which could indicate the presence of a commonantigen as a major target of the psoriatic immune response. HLA-Cw*-0602 protein product binds peptide motifs that areshared between the M proteins of Streptococci and the keratinsK16 and K17 in the skin. This provides a mechanism for psoriasiswhere Streptococcal infection leads to T cell activation. 17. Treatments for Psoriatic Arthritis Symptomatic Therapy Nonsteroidal anti-inflammatory drugs (NSAIDs) Over-the-counter (OTC) medications such as aspirin,naproxen and ibuprofen Prescription strength products (diclophenac,indomethacin, sulindac etc) 18. Treatments for Psoriatic ArthritisDisease-modifying Antirheumatic Drugs(DMARDs) may relieve more severe symptoms and attempt to slow orstop joint/tissue damage and the progression of psoriatic arthritis. Methotrexate (oral and injection) Leflunomide (oral) Sulfasalizine (oral) 19. Treatments for Psoriatic ArthritisBiologics approved by FDA for psoriatic arthritis:Etanercept (Enbrel) Administered as a self injection once or twice weeklyAdalimumab (Humira) Administered as a self injection with a pre-filled syringe typically onceevery other weekGolimumab (Simponi) Administered as a self injection once a monthInfliximab (Remicade) Administered as a self injection once or twice weekly 20. Most Advanced Drugs in Pipeline for Psoriatic ArthritisName SponsorMechanism Route Development phaseApremilast CelgeneAnti- OralIIIinflammatory(PDE4inihibitor)Cimzia UCBTNF blocker Injecta III(Certolizumab)bleTofacitinibPfizer Anti- OralIIIinflammatory(JAK3inhibitor)StelaraCentocor IL-12/-23 Injecta III(Ustekinumab) blocker bleSecukinumabNovartis IL-17 blocker Injecta II(AIN457)ble 21. Psoriasis, Psoriatic Arthritis and DietGeneric ApproachAvoid alcohol refined carbohydrates foods high in saturated fats processed foods gluten, dairy products, citrus, eggs, cornRestrict red meat consumptionConsume fresh fruits and vegetables moderate amounts of protein from fish and fowl fiber 22. Psoriasis, Psoriatic Arthritis and DietIndividualized Approach There are various diagnostic systems focused on determining of foodintolerances and food allergies:Detection of Food Specific Detection of Food Specific Cell Antibodies ResponsesBLOOD Food based neutrophil activation Serum IgG Serum IgG4 Nontraditional Screening Systems Serum IgE Electrodermal screening VAS reflex based screeningSALIVA Applied kinesiology based screening Salivary IgA 23. Psoriasis, Psoriatic Arthritis and Diet Individualized Approach LAB: Institute for Specialized Medicine IgG4 Food Intolerance Screen (FIS-20) RESPONSE0 - negative 1 - borderline2 - mild 3 - moderate 4 - severe 0 1 2 3 4 24. Psoriasis, Psoriatic Arthritis and DietIndividualized ApproachInstitute forSpecializedMedicine:ElectrodermalScreening 25. Psoriasis, Psoriatic Arthritis and DietIndividualized Approach Most of the systems available for food intolerance testing have specificityaround 75-80% Introduction of overlapping systems significantly increases reliability of theresults The ultimate answer is based on foods elimination with their subsequentreintroduction (challenge test) 26. Psoriasis, Psoriatic Arthritis andFood SupplementsCommonly Used Remedies Orphan Remedies Omega-3 polyunsaturated fatty Sea cucumber extractacids Indigo extract Black currant seed oil Vitamin D3 - do not use with Oregon grape (MahoniaCalcipotriene (Dovonex)aquifolium) extact Calcium Yucca Schidigera extract Turmeric Coleus forskohlii Boswellia Devils claw N-acetylglucosamine Probiotics 27. Psoriasis and Heart Attack Recent studies show thatpsoriasis, in and of itself, cancause cardiovascular risk The greater the psoriasisseverity, the greater the risk Controlling inflammationassociated with psoriasis andpsoriatic arthritis showspromising results for reducingcardiovascular risk 28. Atherosclerosis and Other Vascular DiseasesPsoriasis is associated withincreased risk of: Ischemic heart disease - 78% Cerebrovascular disease - 70% Peripheral vascular disease - 98%* after controlling forage, sex, hypertension, diabetesmellitus, dyslipidemia, and tobacco 29. Possible Causes for Increased Risk of Heart Attack in Psoriasis Uncontrolled inflammation leading to blood vessel dysfunction, alteredblood lipids and vascular disease The use of drugs such as corticosteroids, acitretin, and cyclosporine thatalter blood lipid levels The increased prevalence other risk factors: obesity, hypertension, hightriglycerides, smoking 30. Recommendations fromThe National Psoriasis Foundation Medical Board Begin screening for cardiovascular disease risks at age 20 Monitor and modify cholesterol levels Take measures to control depression If you smoke, quit Moderate alcohol intake Eat a healthy diet Exercise 3 times a week for 30 minutes Kimball, et al., J. Amer. Acad. Derm. June, 2008; volume 58(6); 964-969. 31. Other Possible Related Health Conditions: Hypertension Diabetes Cancer Depression Obesity Crohns disease Kimball, et al., J. Amer. Acad. Derm. June, 2008; volume 58(6); 964-969. 32. Dr. Alexander Shikhman MD, PhD, FACRInstitute for Specialized Medicine www.ifsmed.com