During a three-year period (January 2007 to January 2010), all patients with a diagnosis of PsA (according to the Classification Criteria for Psoriatic Arthritis (CASPAR) criteria) [
1] who were non-responders to traditional disease modifying anti-rheumatic drugs (DMARDs) and who were referred to the Regional Reference Center for the treatment of spondyloarthropathies of the Federico II University of Naples to start treatment with TNF-α blockers, were evaluated for enrollment in this study. For all enrolled subjects, exclusion criteria were: lack of informed consent signature, age < 18 years, previous treatment with TNF-α blockers, adequate clinical response to traditional DMARDs treatment, malignancy, hematologic diseases, autoimmune diseases other than PsA, unstable medical conditions, ongoing pregnancy, history of venous and/or arterial thrombosis and of alcohol abuse. After approval of the study by the local Ethics Committee and after informed consent signature, data about age, gender, height, weight, disease duration, disease activity, previous and/or current treatments and vascular risk factors were collected from all patients as previously described [
13]. All PsA subjects had clinically active disease at the time of enrollment and were classified into different clinical subsets (Moll and Wright criteria) [
18]. Briefly, PsA patients were classified as having axial disease if they had at least grade 2 unilateral sacroiliitis in the presence of a combination of inflammatory back pain plus back stiffness. The PsA patients were classified as pure axial if they had no peripheral joint involvement, mixed if they had both peripheral joint arthritis and axial disease, or as having only peripheral joint involvement. The rare mutilans form was diagnosed in the presence of distal interphalangeal joint bone resorption (osteolysis), 'pencil-in-cup' radiographic findings or telescoping motion of the digit. According to the National Cholesterol Education Program (NCEP) criteria [
19], abdominal obesity was defined as a waist circumference ≥102 cm for men and ≥88 cm for women; hypertriglyceridemia, as triglyceride levels ≥150 mg/dL; hypercholesterolemia with low-HDL cholesterol as a total cholesterol ≥200 mg/dL with HDL-cholesterol < 40 mg/dL for men and < 50 mg/dL for women; hypertension as a blood pressure ≥130 and/or 85 mmHg; and impaired fasting glucose (IFG) as a fasting glucose ≥100 mg/dL. Patients were defined as having the MetS if three or more of these VRFs were present. In addition, the presence of CPs and the presence/severity of HS were evaluated in each PsA subject according to previously validated scanning protocols [
13,
16]. All the carotid artery ultrasound examinations were performed by the same operator. After a five minute rest in the supine position, the subjects underwent a bilateral carotid ultrasonography (US) with a 7.5 to 12 MHz linear-array transducer and a duplex scanner (ESAOTE MyLab 25Gold, Genoa, Italy). The ultrasound evaluation was performed longitudinally and transversally by using gray-scale and color-Doppler US imaging. The scan protocol requires the full-length visualization of the near and far wall of the right and left common carotid artery (CCA) and of the bulb in three different projections (anterior, lateral and posterior). The intima-media thickness (IMT) was measured in each of the three projections in the CCA and bulb and the presence of CPs was defined for IMT ≥1.3 mm. The reproducibility of the vascular measurement was evaluated in 20 subjects within 1 week from the first ultrasonographic examination. The overall Pearson's r value for the IMT measurements was 0.89 (
P < 0.001). The presence of HS was assessed with a US diagnostic system (Logiq P5, General Electric, Milan, Italy) with a 3.5-MHz convex probe. All the US determinations were made by the same trained operator. The intra-operator variability, as evaluated in 20 subjects within 1 week from the first ultrasonographic examination, showed an overall r value of 0.92 (
P < 0.001). As previously validated [
16], the presence/severity of HS was defined by comparing the echogenicity of the liver and of the kidney cortex: Grade 0 (absent): iso-echogenicity; Grade 1 (mild): diffuse and homogeneous hyper-echogenicity; Grade 2 (moderate): attenuation of the ultrasonic beam rear; Grade 3 (severe): lack of diaphragm profile visualization. The presence of CPs and of a moderate/severe (2
nd/3
rd degree) HS were recorded in all subjects at baseline (T0). At T0 as well as every three months after having started the treatment with TNF-α blockers, all PsA subjects underwent a complete clinical rheumatologic and laboratory evaluation that included: tender joint count (TJC,
n = 78), swollen joint count (SJC,
n = 76), tender entheseal count (according to the Maastricht Ankylosing Spondylitis Enthesitis Score), psoriasis area severity index (PASI), health assessment questionnaire (HAQ), visual analog scale for pain (VAS), patient global disease activity VAS score, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The data obtained at 12 months were recorded as (T1). During the first 12 months of follow-up (from T0 to T1), PsA subjects were classified as having achieved MDA when fulfilling 5 or more of the following 7 outcome measures at T1: TJC ≤1; SJC ≤1; PASI ≤1 or body surface area ≤3; VAS for pain ≤15; patient global disease activity VAS score of ≤20; HAQ ≤0.5 and tender entheseal points ≤1 [
20]. Otherwise, they were considered as not having achieved MDA (non-MDA). To test the achieving of sustained-MDA (s-MDA), those who had achieved MDA, were re-evaluated every 3 months thereafter during the additional 12-months (T2). s-MDA was defined as fulfilling the same criteria employed for MDA in all the visits carried out between T1 and T2.
The present study protocol has been approved by the Federico II University Local Ethic Committee.
Statistical analysis
Statistical analysis was performed with the SPSS 16 system (SPSS Inc., Chicago, IL, USA). Continuous data were expressed as means ± SD; categorical variables were expressed as percent. The t-test was performed to compare continuous variables; the chi-square test was employed to analyze categorical data. When the minimum expected value was < 5, the Fisher's exact test was used.
A Kaplan-Meier survival model (with the Log-Rank test) was adopted to evaluate the cumulative achieving MDA according to the presence of HS or CPs. To adjust for all the other variables (with emphasis on the presence of the MetS) and to evaluate the achieving of MDA (or of s-MDA), separate COX regression analyses (stepwise method) were adopted, with the achieving MDA (or s-MDA) as the dependent variable and the MetS, CPs, HS, number of CV risk markers, obesity, hypertension, hypercholesterolemia, hypertriglyceridemia, impaired fasting glucose, smoking habit, TJC, SJC, tender entheseal count, PASI, HAQ, VAS for pain, patient global VAS, ESR, CRP, concomitant treatment with methotrexate, gender, age and disease duration as independent variables. Multi-collinearity effect in multivariable regression models was excluded by a stepwise approach with each variable included for P < 0.05 and excluded for P > 0.1. A tolerance test was employed to exclude models in which the sum of the values exceeded the sum of the variances for all variables. All the results are presented as two-tailed values with statistical significance if P values < 0.05.
As to the sample size calculation, to plan a study with a minimal pre-defined Hazard Ratio (HR) ≥1.4, an accrual interval of 3 years, and a follow-up period of 24 months, at least 222 subjects are needed to achieve a > 80% power with an 5% α error. With an expected drop-out of 25% during the follow-up, 280 subjects were enrolled in the study.