Psoriatic arthritis (PsA)
Psoriasis is a chronic inflammatory skin disease affecting 3% of the population. Psoriatic arthritis (PsA) is an inflammatory arthritis that affects approximately 30% of people with psoriasis and can lead to significant joint damage and disability. Psoriasis and PsA, collectively termed psoriatic disease, involve inflammation of the skin and joints. Patients with psoriatic disease encounter substantial barriers in managing their conditions, which often present simultaneously with other co-morbidities or complications, such as cardiovascular diseases. While psoriatic disease tends to be equally distributed among males and females, it affects patients of the different sexes in unique ways. Female patients tend to respond less favourably to treatments and may experience delays in specialty care and diagnosis.
With the goal of early detection and equitable delivery of care for all patients to improve health outcomes, our team is focused on understanding the risk factors for developing PsA among men and women with psoriasis. With earlier detection and an improved care delivery, patients can benefit from receiving earlier treatment and possibly even future prevention of the disease.
Psoriatic Arthritis Program
2022 – 2023 Annual Impact Report
Osteoarthritis (OA) is the most common form of arthritis worldwide, and a leading cause of disability among older adults. One in 3 people over age 65, and disproportionately more women than men, are living with OA. OA is a complex, chronic condition, characterized by loss of the cartilage in joints. Without this protective coating, bone rubs against bone, causing inflammation and resulting in joint pain and stiffness. In older adults, OA frequently exists alongside other common chronic conditions and may increase the risk for worse outcomes from these conditions. Management should be tailored to the individual and focus on core treatments, including physical activity/exercise coupled with self-management strategies, education, and weight loss as relevant. Given the growing burden and impact of OA, enhanced effort is required to identify better – more effective and safe – treatments for the majority of people with OA who are living with other chronic conditions.
Psoriatic Arthritis Research Program
The Psoriatic Arthritis Program at Women’s College Research Institute is a clinical research program that was founded in 2016 by Dr. Lihi Eder. Dr. Eder is a clinician-scientist and staff rheumatologist at WCH and holds a Tier 2 Canada Research Chair in Inflammatory Rheumatic Diseases. Her clinical and research expertise are in the fields of PsA, musculoskeletal ultrasound, and cardio-rheumatology. The program includes a specialty PsA Clinic for individuals with PsA that integrates clinical research through standardized collection of clinical information and biological samples. The aim of our research program is to improve the lives of men and women with PsA by discovering innovative, equitable and efficient ways to facilitate early diagnosis and thus early intervention to prevent morbidity from PsA. With funding from a number of national and international granting agencies (CIHR, Canada Research Chair, Arthritis Society, National Psoriasis Foundation, GRAPPA), our team is currently undertaking research studies in the fields of clinical epidemiology and translational research in PsA.
Canadian Osteoarthritis Research Program (CORP)
Led by Dr. Gillian Hawker, our work brings together a multidisciplinary team of researchers from several institutions and a variety of disciplinary backgrounds including rheumatology, orthopedic surgery, physical therapy, epidemiology/health services research, mental health, and the behavioural sciences. With funding from a number of granting agencies (CIHR, PSI Foundation) and collaboration with Arthritis Society Canada, our team is working to develop multidisciplinary knowledge about best practices, and new models, to improve care and reduce the impact of OA in people living with this condition. Current research is focused on OA management through early and appropriate promotion of physical activity. With an overarching goal of early identification and diagnosis of OA, and incorporation of behaviour change techniques to encourage physical activity in order to reduce pain, improve function, and protect against adverse health outcomes such as obesity, diabetes and cardiovascular disease, all common comorbidities in individuals with OA.
- Psoriatic arthritis
- Musculoskeletal ultrasound
- Joint replacement
PsA Research Team
The PsA Research Team (from left to right): Lily He (Research Coordinator), Sanjana Tarannum (MSc Student), Dr. Sahil Koppikar (Rheumatologist), Dr. Lihi Eder (Rheumatologist & Director), Fahmeen Afgani (Program Manager), Sydney Thib (Research Coordinator), Keith Colaco (PhD Candidate), Shani Nagler (Research Coordinator).
|Director||Dr. Lihi Eder, MD, PhD|
|Staff Rheumatologist||Dr. Sahil Koppikar, MD|
|Program Manager||Fahmeen Afgani|
|Research Associate||Dr. Keith Colaco, PhD|
|Research Coordinators||Sydney Thib |
Steven Dang, MSc Student
Sanjana Tarannum, MSc Student
Dr. Jessica Gutierrez, MD, Clinical Research Fellow
Dr. Sahil Koppikar, MD
Dr. Pamela Diaz, MD
Dr. Antonio Wong, MD
Dr. Keith Colaco, PhD
|Past Summer Students||Andreea Damien, MD Candidate, University of Toronto|
Sivakami Mylvaganam, MD Candidate, University of Toronto
Shaima Helal, MD Candidate, Queen’s University
Dr. Samantha Sarabia, MD, Queen’s University
Dr. Curtis Sobchak, MD, University of Toronto
Dr. Micaela Jacobson, MD, University of Ottawa
Dr. WanLi Zhou, MD, University of Toronto
CORP Research Team
Gillian Hawker, MD, MSc – Director
Lauren King, MD, MSc – PhD Candidate
Esther Waugh, BScPT, PhD – Scientific Associate
Ian Stanaitis, BMSc – Research Coordinator
Vivian Hung, MPH – Research Assistant
- Sex- And Gender-based analysis of Effectiveness of advanced therapies in Psoriatic Arthritis (SAGE-PsA)
- Dietary Interventions in Psoriatic Arthritis (DIPSA) Study
- Prognostic and Genetic Studies in Psoriasis and Psoriatic Arthritis: IPART (International Psoriasis and Arthritis Research Team)
- Deep cellular immune profiling in psoriatic arthritis: A step towards individualized therapy
- The Diagnostic Ultrasound Enthesitis Tool (DUET) Study: Development of a Sonographic Enthesitis Score for Early Diagnosis of Psoriatic Arthritis
- Preventing Arthritis In A Multi-Center Psoriasis At-Risk Cohort (Multi-Center PAMPA Study)
- Treating Osteoarthritis with Exercise in Patients with Diabetes Mellitus (TOP-DM)
- Arthritis Society Diabetes & Osteoarthritis Program
- The Prevalence and Impact of Symptomatic Knee Osteoarthritis in Patients with Type 2 Diabetes Mellitus: A Cross-sectional Study
Key Findings & Publications
Our studies identified differences in clinical presentation and response to treatment among men and women with PsA. Our research program supported by the Canada Research Chair program aims to study sex (biological) and gender (socio-cultural) mechanisms underlying these disparities in treatment. This will inform the development of a sex/gender-based approach to the management of patents in clinical practice.
Eder L, Thavaneswaran A, Chandran V, Gladman DD.Ann Rheum Dis. 2013 Apr;72(4):578-82. doi: 10.1136/annrheumdis-2012-201357. Epub 2012 May 15.
Enthesitis, an inflammation at the insertion site of the tendon/ligament to bone, is a key feature of PsA. Ultrasound assists with early diagnosis of enthesitis and sonographic enthesitis is a marker of radiographic joint damage in PsA. Our team studies the role of enthesitis in PsA using musculoskeletal (MSK) ultrasound to help improve the understanding of underlying mechanisms of PsA. Additionally, we lead an international, multi-center study aimed at developing a new scoring method for sonographic enthesitis.
- Polachek A, Cook R, Chandran V, Gladman D, Eder L. The association between sonographic enthesitis and radiographic damage in psoriatic arthritis. Arthritis Res Ther. 2017; 19:189.
- Polachek A, Cook R, Chandran V, Abji F, Gladman D, Eder L. The association between HLA genetic susceptibility markers and sonographic enthesitis in psoriatic arthritis. Arthritis Rheumatol. 2017.
- Tom S, Zhong Y, Cook R, Aydin SZ, Kaeley G, Eder L. Development of preliminary ultrasonographic enthesitis score in psoriatic arthritis – GRAPPA ultrasound working group. J Rheumatol 2019; 46:384-90.
An additional field of research is the epidemiology of psoriatic disease, with an emphasis on the pre-clinical phases of PsA. These studies have suggested that a preclinical phase, characterized by non-specific MSK symptoms, exists in PsA patients prior to the diagnosis of the disease. We have also described other risk factors for the disease among patients with psoriasis. These findings inform our current efforts to develop a new prediction tool for PsA among psoriasis patients that will help identify high risk individuals who can benefit from preventative interventions.
- Eder L, Polachek A, Rosen CF, Chandran V, Cook R, Gladman DD. The development of psoriatic arthritis in patients with psoriasis is preceded by a period of nonspecific musculoskeletal symptoms: A prospective cohort study.Arthritis Rheumatol 2017; 69:622-629.
- Eder L, Haddad A, Rosen CF, Lee KA, Chandran V, Cook RJ, Gladman DD. The incidence and risk factors for psoriatic arthritis in patients with psoriasis: A prospective cohort study.Arthritis Rheumatol 2016; 68:915-23.
- Eder L, Shanmugarajah S, Thavaneswaran A, Chandran V, Rosen CF, Cook RJ, Gladman DD. The association between smoking and the development of psoriatic arthritis among psoriasis patients.Ann Rheum Dis. 2012; 71:219-24.
Our studies have contributed to a growing body of knowledge about cardio-metabolic diseases in rheumatic patients. A significant proportion of patients with rheumatic diseases develop cardiovascular events, such as heart attack and stroke, during the course of their disease. Increased cardiovascular risk is associated with a combination of traditional cardiovascular risk factors and disease activity. Gaps in knowledge and care among these patients led us to develop an interdisciplinary clinical and research Cardio-Rheumatology program that aims to improve awareness, education, and research in this field. For more information about our cardio-rheumatology program, please visit: https://www.womenscollegehospital.ca/care-programs/cardio-rheumatology-clinic
- Eder L, Joshi AA, Dey AK, Cook R, Siegel EL, Gladman DD, Mehta NN. TNF inhibitors are associated with reduced indices of subclinical atherosclerosis in patients with psoriatic disease.Arthritis Rheumatol. 2018; 70:408-16.
- Polachek A, Touma Z, Anderson M, Eder L. Risk of cardiovascular morbidity in psoriatic arthritis: A meta-analysis of observational studies.Arthritis Care Res (Hooboken) 2017; 69:67-74.
- Eder L, Wu Y, Chandran V, Cook R, Gladman DD. Incidence and predictors for cardiovascular events in patients with psoriatic arthritis.Ann Rheum Dis. 2016; 75:1680-6.
- Eder L, Chandran V, Gladman DD. The Framingham risk score underestimates the extent of subclinical atherosclerosis in patients with psoriatic disease.Ann Rheum Dis. 2014; 73:1990-6.
- Hawker GA, Bohm E, Dunbar MJ, Faris P, Jones CA, Noseworthy T, Ravi B, Woodhouse LJ, Marshall DA. Patient appropriateness for total knee arthroplasty and predicted probability of a good outcome. RMD Open 2023;9:e002808. doi: 10.1136/rmdopen-2022-002808.
- Joint Action Podcast – When is a joint replacement appropriate? with Prof Gillian Hawker
- King LK, Waugh EJ, MacKay C, Stanaitis I, Krystia O, Stretton J, Ross S, Brady S, Weisman A, Lipscombe L, Hawker GA. Formulating Knee Osteoarthritis Management Plans Taking Type 2 Diabetes into Account: Qualitative Study of Arthritis Therapists Using Theoretical Domains Framework. J Rheumatol. 2022:jrheum.220535. doi: 10.3899/jrheum.220535. Epub ahead of print.
- Hawker GA, Conner-Spady BL, Bohm E, Dunbar MJ, Jones CA, Ravi B, Noseworthy T, Woodhouse LJ, Faris P, Dick D, Powell J, Paul P, Marshall DA; BEST-Knee Study Team. Relationship Between Patient-Reported Readiness for Total Knee Arthroplasty and Likelihood of a Good Outcome at One-Year Follow-Up. Arthritis Care Res (Hoboken). 2022;74(8):1374-1383.
- King LK, Krystia O, Waugh EJ, MacKay C, Stanaitis I, Stretton J, Weisman A, Ivers NM, Parsons JA, Lipscombe L, Hawker GA. Barriers and enablers to health care providers assessment and treatment of knee osteoarthritis in persons with type 2 diabetes mellitus: A qualitative study using the Theoretical Domains Framework. Osteoarthritis and Cartilage Open. 2022;4(4):100299.
- King LK, Krystia O, Waugh EJ, MacKay C, Stanaitis I, Stretton J, Weisman A, Ivers NM, Parsons JA, Lipscombe L, Hawker GA. Understanding the behavioural determinants of seeking and engaging in care for knee osteoarthritis in persons with type 2 diabetes mellitus: A qualitative study using the theoretical domains framework. Osteoarthritis and Cartilage Open. 2022;4(4):100305.
- Hawker GA, Bohm E, Dunbar MJ, Jones CA, Noseworthy T, Marshall DA; BEST-Knee Study Team. The Effect of Patient Age and Surgical Appropriateness and Their Influence on Surgeon Recommendations for Primary TKA: A Cross-Sectional Study of 2,037 Patients. J Bone Joint Surg Am. 2022;104(8):700-708.
- King LK, Hawker GA, Stanaitis I, Woodhouse L, Jones CA, Waugh EJ. Minimal clinically important difference for improvement in six-minute walk test in persons with knee osteoarthritis after total knee arthroplasty. BMC Musculoskelet Disord. 2022;23(1):307.
- King LK, Waugh EJ, Jones CA, Bohm E, Dunbar M, Woodhouse L, Noseworthy T, Marshall DA, Hawker GA; BEST-Knee Study Team. Comorbidities do not limit improvement in pain and physical function after total knee arthroplasty in patients with knee osteoarthritis: the BEST-Knee prospective cohort study. BMJ Open. 2021;11(6):e047061.
- Hawker GA, Conner-Spady BL, Bohm E, Dunbar MJ, Jones CA, Ravi B, Noseworthy T, Dick D, Powell J, Paul P, Marshall DA; BEST-Knee Study Team. Patients’ Preoperative Expectations of Total Knee Arthroplasty and Satisfaction With Outcomes at One Year: A Prospective Cohort Study. Arthritis Rheumatol. 2021;73(2):223-231.
- King LK, Marshall DA, Jones CA, Woodhouse LJ, Ravi B, Faris PD, Hawker GA; BEST-Knee Team. Are medical comorbidities contributing to the use of opioid analgesics in patients with knee osteoarthritis? Osteoarthritis Cartilage. 2020;28(8):1030-1037.
- King LK, Marshall DA, Faris P, Woodhouse LJ, Jones CA, Noseworthy T, Bohm E, Dunbar MJ, Hawker GA; BEST-Knee Research Team. Use of Recommended Non-surgical Knee Osteoarthritis Management in Patients prior to Total Knee Arthroplasty: A Cross-sectional Study. J Rheumatol. 2020;47(8):1253-1260.
International Psoriasis and Arthritis Research Team (IPART)
IPART is an international network of dermatologists and rheumatologists that focus on psoriasis and PsA, as well as other multi-disciplinary collaborators, including geneticists, epidemiologists and biostatisticians. The program focuses on the biological basis of psoriatic disease with an emphasis on predicting onset and severity of PsA using clinical and genetic variables, and identification of disease biomarkers.
IPART consists of several psoriatic disease cohorts across Canada, USA and Israel. These cohorts are followed over time and consist of detailed clinical, laboratory, imaging and genetic data. There are currently over 5000 patients with psoriasis and PsA patients enrolled in IPART, making it one of the richest sources of research data in the world for studying various aspects of psoriatic disease. Our collaboration with IPART led to discoveries in the fields of genetic, imaging and co-morbidities in PsA.
The PsA Program studies the application of musculoskeletal ultrasound as point of care for the management of PsA. The program has been involved in dissemination of musculoskeletal ultrasound among rheumatologists by offering one of the only fellowship programs in point-of-care MSK ultrasound in Canada. We extensively used ultrasound to investigate clinical outcomes in PsA and developed sonographic outcome measures. Dr. Eder is a recognized expert in musculoskeletal ultrasound, as she serves as Research Director of the Canadian Rheumatology Ultrasound Society (CRUS) and leads an international initiative through GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis) to develop sonographic scoring systems in PsA. She is extensively involved in teaching musculoskeletal ultrasound to rheumatologists at the local, national and international levels.
Cardiovascular diseases remain a major cause of morbidity and mortality in patients with established rheumatic diseases including PsA. Cardiovascular risk factors are often undertreated in psoriatic patients and there is uncertainty regarding the appropriate approach for cardiovascular risk stratification in these patients. Our work aims to address these gaps in knowledge and care by investigating the contributing factors for cardiovascular diseases and identifying new modalities to improve cardiovascular risk stratification in psoriatic patients.
In 2017, Dr. Eder co-founded the Cardio-Rheumatology Program (in collaboration with the Division of Cardiology led by Dr. Paula Harvey). The global aim of the program is to reduce the burden of cardiovascular diseases in patients with rheumatic conditions through improved clinical care, research and education. The program includes a primary prevention clinic (Cardio-Rheum Clinic), the first of its kind in Canada, which uses advanced imaging and laboratory markers to improve the detection of high-risk patients and improve the control of their cardiovascular risk factors.
The Program holds an annual symposium for health care providers and researchers that helps to disseminate the results of our research in the general medical community.
Join Our Team
We regularly recruit undergraduate and medical students through the Summer Research Program at Women’s College Research Institute. Interested applicants should visit the Summer Student Research Program page for more information.
In addition, different forms of training are available to those interested in applying to MSc or PhD graduate programs in the Institute of Medical Science or Institute of Health Policy, Management and Evaluation at the University of Toronto.
For further information about these opportunities as they relate to the PsA research team, please contact Sydney Thib: Sydney.Thib@wchospital.ca
For further information about these opportunities as they relate to the CORP research team, please contact Ian Stanaitis: Ian.Stanaitis@wchospital.ca
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Videos and Podcasts
- Gerald’s journey with PsA
- Unravelling the risks in psoriatic disease
- Diagnostic challenges of psoriatic arthritis
- Looking to collaborative models of care to improve primary prevention of cardiovascular disease in patients with inflammatory arthritis
- Psound Bytes Podcast – Is Enthesitis Unique to Psoriatic Arthritis?