(Guideline for Management of

Psoriatic Arthritis)

.. 2555

(spondyloarthropathy) (psoriasis)

.. 2553-2555

. ........................................................................................................... 07
................................................................................................................................... 09
......................................................................................................10
..................................................................................................................................................... 18
1 (levelsofevidence) ...............................18

(gradingofrecommendations)
2 ..............................19
3 CASPAR ................... ....20
4 ............................................................................. 21
5................................................................................... .........22
6 .................. 23
7 DMARDs .......................... 24
8 .................................25
DMARDs TNF-antagonist
9 ........................... 26
DMARDs
10 Physician Global Assessment (PGA) Likert Scale............ 27
11 78 ............... 28

76
12 ...............................30
13 Psoriasis Area and Severity Index (PASI)...........................................................31
14 ...................................................32
15 Classification of functional capacity in rheumatoid arthritis.................... 34


(Guideline for Management of
Psoriatic Arthritis)

(psoriaticarthritis,PsA)

3-23 1 56-1500 1 1-2
(psoriasis) 7-48 3
3050



1-2
4-5
6

(disease-modifyinganti-rheumaticdrugs,DMARDs)

DMARDs

(
1)electronicdatabase(Medline)systematicreviewdatabase
(Cochranesystematicreview)..
2554 7-15

DMARDs

DMARDs
(effectiveness)(safety)

(juvenilePsA) (psoriaticskin
disease)

spondyloarthropathy1991
proposalofEuropeanSpondyloarthropathyStudyGroup(ESSG)

2-3 (oligoarthritis) (asymmetry) (distal

phalangealjoints)
(spondyloarthritis)ankylosingspondylitis
dactylitis
(conjunctivitis),uveitis,aorticinsufficiency


Moll&WrightCriteriaofPsoriaticarthritis( 2)
rheumatoidfactor
(91-94)(
) ClAS
sificationCriteriaforPsoriaticArthritis(CASPAR)( 3)
rheumatoidfactor

( 4)( 5)
peripheraljoint( 6)
(non-steroidalanti-inflammatorydrugs,NSAIDs)
(1,A)(intra-articularsteroidinjection)(4,D)

NSAIDs/
1 DMARDs( 7)
sulfasalazine(1a,A) 16-22,leflunomide(1b,A) 23,methotrexate(1b,B) 24-26,
cyclosporine(1b,B) 16,27 intramusculargoldsalt(1b,B)
28-29azathioprine(2b,B)
DMARDs 30anti-malarialdrug(3,D)
31 TNF-
antagonists(1a,A) 32-38
DMARDs (

10

 biologicagents)
DMARDs 39 methotrexate(1b,A),cyclosporine(1b,A),sulfasalazine(1b,A),leflunomide(1b,A),
TNF-antagonists(1b,A)

40-41

axialinvolvement(
)
NSAIDs(1b,A),(4,D)(1b,A)
(1b,A)NSAIDs2
3 DMARDs(4,D)
DMARDs3BASDAI
4physicianglobalassessment2
(1a,A)
enthesitis/dactylitis
NSAIDs(4,D),(4,D) (4,D)
DMARDs(4,D)sulfasalazine
enthesitis(1b,A) 22,42DMARDs
TNF-antagonists
(1b,A) 34-35,43( biologicagents
)

DMARDs
DMARDs
( 8)

11

( 9)

12


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15

27. FraserAD,vanKuijkAW,WesthovensR,KarimZ,WakefieldR,Gerards
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17

 1
(levels of evidence)
(grading of recommendations)
(Levels of Evidence, LoE)
1a
1b
2a
2b
3
4

meta-analysis randomized controlled trials

(RCT)
RCT 1
well-designed controlled study
randomization 1
well-designed quasi-experimental study 1

well-designed non-experimental descriptive studies

comparative studies, correlation studies and case control studies
/

(Grading of Recommendations, SoR)

A
B
C
D

1
2 1
3 1 2
4 2 3

18

Moll & Wright 1973

1. inflammatory arthritis
( / sacroiliac /)
2.
3.

5
1.

(distal interphalangeal DIP joint)

2. 2-3 (asymmetrical oligoarthritis)

3. (polyarthritis)
4. (spondylitis)
5. (arthritis mutilans)

19

 3
CASPAR

3
1

(2 )

(1 )

latex agglutination assay

enzyme-linked immunosorbent assay nephelometry (1 )

dactylitis

dactylitis (1 )

dactylitis (1 )

91.4

onycholysis, pitting nail

hyperkeratosis (1 )

(
(1 )

juxta-articular new bone formation / (1 )

CASPAR 98.7

20

( GRAPPA Group for Research and Assessment of Psoriasis and

Psoriatic Arthritis. Ritchlin CT, et al. Ann Rheum Dis 2009;68:1387-94)

21

( Group for Research and Assessment of Psoriasis and Psoriatic

Arthritis GRAPPA. Ritchlin CT, et al. Ann Rheum Dis 2009;68:1387-94)
(mild)

(severe)

(moderate)

BSA < 5, PASI < 5

DLQI <10, PASI < 10

BASDAI >
4

12

2 2

BSA = Body Surface Area

PASI = Psoriatic Area and Severity Index
DLQI = Dermatology Life Quality Index
BASDAI = Bath Ankylosing Spondylitis Disease Activity Index

22

BSA > 10, DLQI >10,

PASI > 10

SSZ = Sulfasalazine
LEF = Leflunomide
MTX = Merhotrexate
CsA = Cydosporin A

23

 7
DMARDs
DMARDs

(standard target dose)

Methotrexate (evidence B)
Sulphasalazine (evidence A)

7.5-15 ./ ( 25 ./)
40 // 2-3 ( 3 /
)

Leflunomide (evidence A )
Intramuscular gold injection (evidence D)
Azathioprine (evidence D)
Cyclosporine (evidence B)

10-20 ./
40 ./
2 // 2
3-5 ././

(therapeutic dose) DMARDs

Methotrexate
Sulphasalazine
Leflunomide
Intramuscular gold injection
Azathioprine
Cyclosporin A

24

7.5 - 10 ./
1.5 / 2-3
10-20 ./
20 ./
50 .
2.5-5 ././

DMARDs TNF-antagonist

. MTX Methotrexate, SSZ Sulphasalazine, LEF Leflunomide, Gold inj. Gold

salt injection, AZA Azathioprine, CyA Cyclosporin A, Anti-TNF Anti-tumor necrosis
factor drugs.
. CBC Complete blood count, UA Urine exam, Cr Serum creatinine, AST
Aspartate aminotranferase, ALT Alanine aminotransferase, G6PD Glucose-6-phosphate
dehydrogenase screening test ().
. CXR chest x-rays, BP Blood pressure measurement, elect Serum electrolytes, lipid Lipid profile.
. HBV serology hepatitis B surface antigen (HbsAg), hepatitis B antibodies
(anti-HBs), hepatitis B core antibodies (anti-HBc); HCV serology hepatitis C antibodies
(Anti-HCV), anti-HIV anti-HIV antibodies
. PPD - Purified protein derivative or tuberculin skin test, Quanti f.TB Quantiferon

TB gold test or interferon-gamma release assay.

25

DMARDs

Physician Global Health Assessment (PGA)

VAS (visual analog scale) pain score

Swollen joint count tender joint count

dactylitis enthesitis

BASDAI

Functional class

PASI DLQI

CBC, urine exam, BUN, Cr

2-6 3
3

liver function test

ESR, CRP

(peripheral joint, chest)

1-2

26

 10
Physician Global Assessment (PGA)
Likert Scale
0

27

 11
78
76

(tender)

(swollen)

(tender)

(swollen)

Temperomandibular
Sternoclavicular
Acromioclavicular
Shoulder
Elbow
Wrist
CMC
MCP1
MCP2
MCP3
MCP4
MCP5
PIP1
PIP2
PIP3
PIP4
PIP5
DIP2
DIP3
DIP4
DIP5
Hip
Knee

28

XXXX

XXXXX

Ankle
Tarsi
MTP1
MTP2
MTP3
MTP4
MTP5
Toes(PIP)1
PIP2
PIP3
PIP4
PIP5
Toes (DIP)2
DIP3
DIP4
DIP5

29

 12
Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)

1
1.
0 1 2 3 4 5 6 7 8 9 10

2.
0 1 2 3 4 5 6 7 8 9 10

3.

0 1 2 3 4 5 6 7 8 9 10
4.

0 1 2 3 4 5 6 7 8 9 10

5.
0 1 2 3 4 5 6 7 8 9 10
6.


0 1 2 3 4 5 6 7 8 9 10

30 11>2

1-4+56=
BASDAISCORE==
5

30

50
10

 13
Psoriasis Area and Severity Index (PASI)
Tick ONE box for each r egion for A,B,C,D

31

 14
Dermatology Life Quality Index (DLQI)

DLQI Score: _____________

_ _ ______ ____________________
Case No. _______ ___ / ______ / ______

?
a ()
1. , , ,

(3)
(2)
(1)
(0)

2. ,

(3)
(2)
(1)
(0)

3.

(3)
(2)
(1)
(0)

4.

(3)
(2)
(1)
(0)

32

5.

(3)
(2)
(1)
(0)

6.

(3)
(2)
(1)
(0)

7.

8.

(3)
(2)
(1)
(0)

(3)
(2)
(1)
(0)

9.

(3)
(2)
(1)
(0)

10.

,

(3)
(2)
(1)
(0)

33

 15
Classification of functional capacity in rheumatoid arthritis
(Steinbrocker criteria)
Class I

Class II

Class III

Class IV

Steinbrocker O, Traeger CH, Batterman RC: Therapeutic criteria in rheumatoid

arthritis. JAMA 140:659-662, 1949

34


..2553-2555

35

..2553-2555

...
. ..
...
..
..
...
...
. ..
...
...
...
. () ..

36