What is the relevance of structural damage in psoriatic arthritis?

Subclinical Psoriatic Arthritis: Does it Really Exist?

In this episode of RheumaCast, we discuss the evolving concept of subclinical psoriatic arthritis and the challenges associated with its definition and clinical relevance. The episode explores current frameworks describing the transition from psoriasis to psoriatic arthritis, highlighting the limitations of existing definitions, particularly the reliance on arthralgia and imaging findings in the absence of clinical synovitis. A central theme is the risk of misclassification and overtreatment, given the lack of validated biomarkers, the heterogeneity of psoriatic disease, and the limited specificity of imaging abnormalities. The discussion also draws parallels with preclinical rheumatoid arthritis, emphasizing both opportunities and pitfalls of early intervention strategies. Finally, we address key research priorities, including longitudinal psoriasis cohorts, advanced imaging approaches, and multiomic biomarker development, with the goal of improving risk stratification and enabling targeted prevention while avoiding overdiagnosis. This episode is based on publication Kharouf F, et al. Ann Rheum Dis 2026, doi: 10.1016/j.ard.2026.03.011, and developed with NotebookLM.

What is the relevance of structural damage in psoriatic arthritis?

In this episode of RheumaCast, we discuss the functional consequences of structural joint damage in psoriatic arthritis based on data from a large, prospectively followed cohort. While inflammation is often considered the main driver of impaired physical function, this study provides a more nuanced view. Radiographic damage, particularly severe joint destruction, shows an independent association with functional impairment—even after adjusting for disease activity and other confounders. Importantly, not all damage is equal: mild or moderate changes appear to have limited functional impact, whereas complete joint destruction demonstrates a clear and clinically meaningful effect, with a dose–response relationship. We also explore how these findings should influence treatment strategies, emphasizing early intervention and prevention of irreversible damage rather than relying solely on control of inflammatory activity. This episode places structural damage into context and highlights its relevance for long-term patient outcomes in PsA. This episode is based on publication Mehta P, et al. Arthritis Rheumatol 2026; doi:10.1002/art.70145 and developed with NotebookLM.

Do we need new therapies in spondyloarthritis?

This episode of RheumaCast explores why many individuals with axial spondyloarthritis (axSpA) fail to achieve remission, despite access to advanced therapies. The discussion centers on two key factors often overlooked in daily practice: diagnostic inaccuracy and the presence of non-inflammatory pain mechanisms such as nociplastic and neuropathic pain. While a small group of patients presents with true treatment-refractory axSpA—characterized by persistent inflammation despite multiple advanced therapies—most cases of apparent non-response are explained by symptoms not driven by inflammation. These require different management strategies, including psychological support, structured exercise, and targeted pharmacological approaches. The episode also addresses emerging therapeutic concepts, including dual-targeted strategies, modulation of the HLA-B27 immunopeptidome, and novel immune targets. Making remission a reality for all patients will depend on both better use of existing treatments and the development of new ones. This episode is based on the publication: Poddubnyy D, et al. EULAR Rheumatol Open 2025;1:484–487 and developed with NotebookLM.

Sex Differences in Treatment Response in Axial Spondyloarthritis

In this episode of RheumaCast, we explore new data from the international PROOF cohort on sex-specific differences in achieving disease control in axial spondyloarthritis (axSpA). The authors present compelling evidence that women with non-radiographic axSpA (nr-axSpA) are significantly less likely than men to reach low disease activity or inactive disease—despite similar treatment approaches and TNFi use. What’s behind this disparity? We discuss potential contributors, including nociplastic pain mechanisms, mechanical mimics like osteitis condensans ilii, and sex-specific differences in sacroiliac joint anatomy. The findings highlight the urgent need for accurate diagnosis and a nuanced approach to treatment in women with axSpA—especially in the non-radiographic stage. This episode is based on the publication: Poddubnyy D, et al. Rheumatology 2025; doi:10.1093/rheumatology/keaf447 and developed with NotebookLM.

The Imaging Crisis in Axial Spondyloarthritis: Between Early Diagnosis and Overdiagnosis

In this episode of RheumaCast, we dive into the ongoing debate around imaging in axial spondyloarthritis (axSpA). While MRI has revolutionized early detection of sacroiliitis, it has also created new diagnostic challenges. We discuss why bone marrow edema alone is not enough for a confident diagnosis, how mechanical stress and anatomical variations complicate interpretation, and why we might be facing an "imaging crisis" in axSpA. We explore current workarounds—pattern recognition, quantification of lesions, contextual interpretation—and their limitations. The conversation also highlights emerging solutions, from advanced imaging techniques and AI-based analysis to the critical role of expert radiology assessment. Tune in to understand why balancing early diagnosis with diagnostic accuracy is essential to avoid misclassification, overtreatment, and ultimately to improve patient outcomes. This episode is based on the publication: Diekhoff T, Poddubnyy D, et al. Lancet Rheumatol 2025; Published online May 16, 2025. doi:10.1016/S2665-9913(25)00108-0 [https://www.sciencedirect.com/science/article/pii/S2665991325001080] and developed with NotebookLM.