Amara Ezeonyeji

Objective: We aimed to compile evidence for the efficacy and safety of therapeutic options for the peripheral arthritis domain of psoriatic arthritis (PsA) for the revised 2021 Group in Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) treatment recommendations.Methods: A working group consisting of clinicians and patient research partners was convened. We reviewed the evidence from new randomized controlled trials (RCTs) for PsA treatment from February 19, 2013, to August 28, 2020. We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE)-informed approach to derive evidence for the classes of therapeutic options for 3 patient groups: (1) naïve to treatment, (2) inadequate response to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), and (3) inadequate response to biologic DMARDs (bDMARDs). Recommendations were derived through consensus meetings.Results: The evidence review included 69 RCTs. We derived GRADE evidence for each class of therapeutic options and achieved consensus for the recommendations. For patients naïve to treatment, the working group strongly recommends csDMARDs (methotrexate, sulfasalazine, leflunomide) and phosphodiesterase 4 inhibitors, and emphasizes regular assessment and early escalation to achieve treatment target. bDMARDs (tumor necrosis factor inhibitors [TNFi], interleukin 17 inhibitors [IL-17i], IL-12/23i, IL-23i) and Janus kinase inhibitors (JAKi) are also strongly recommended. For patients with inadequate response to csDMARDs, we strongly recommend TNFi, IL-17i, IL-12/23i, IL-23i, and JAKi. For those who had prior experience with bDMARDs, we strongly recommend a second TNFi, IL-17i, IL-23i, and JAKi. The evidence supporting nonpharmacological interventions was very low. An expert panel conditionally recommends adequate physical activity, smoking cessation, and diet to control weight gain.Conclusion: Evidence supporting optimal therapy for the peripheral arthritis domain of PsA was compiled for the revised 2021 GRAPPA treatment recommendations.

Background: Sir William Osler once wrote: “He, who knows syphilis, knows medicine”. Whilst the Tuskegee Syphilis trials live in infamy, the advent of succesful penicillin treatment and sexual health education resulted in the lowest recorded incidence ever in 2001¹. Unfortunately, cases of syphilis have nearly tripled in the past decade (from 2,847 in 2009 to 7,541 in 2018 in the UK)¹. WHO now estimates the global median prevalence of Syphilis, among men who have sex with men, is 6%² The current cohort of clinicians will therefore have limited clinical experience of Syphilis, which can often mimic rheumatic conditions. We present the clinical experience of a tertiary teaching centre hospital. Objectives: To identify the scope of clinical cases, with a diagnosis of Syphilis, during 2018-2019 at St Georges University Hospital, London, UK. Methods: Clinical cases were identified by health professionals and a retrospective review of medical records was undertaken. Results: There were 4 cases identified during 2018-19. Case 1: The patient was diagnosed with bilateral uveitis secondary to primary syphilis, and immunosuppression may have contributed to this. Case 2: The rash developed after the initial presentation and an extended infection screen was performed. Case 3: The patient had a 6 month duration of symptoms and had had a negative sexual health screen 1 year prior to presentation. Case 4: The patient had no features of extra pulmonary sarcoidosis and an infectious screen was undertaken. All 4 cases were referred to the Infectious Disease Unit for treatment. 3 patients received standard treatment with Penicillin, and 1 patient received an oral course of Doxycycline, due to a penicillin allergy. 2 of the 4 cases had complete resolution of symptoms, and 2 of the cases had only partial resolution of symptoms at the time of publication. Conclusion: Syphilis can present with an inflammatory arthritis, PMR and GCA –type symptoms, ocular inflammation, neurological disturbance and rashes that can mimic autoimmune conditions. Our cases highlight the increasing incidence, as well as the risk of reactivation following immunosuppression. Current practice does not advise routine testing for syphilis prior to initiation of immunosuppressive therapy. However the rising incidence should prompt careful evaluation, and detailed sexual history, particularly in high risk groups. The diagnostic test interpretation and treatment requires close collaboration with Infectious Diseases Specialists. References: [1]https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/805903/2018_Table_1_STI_diagnoses_and_rates_in_England_by_gender.ods [2]Report on global sexually transmitted infection surveillance 2018, WHO, ISBN: 978-92-4-156569-1 Disclosure of Interests: None declared