Q&A: Psoriatic arthritis ‘not diagnosed enough’
Approximately 125 million people worldwide, including more than 8 million Americans, have psoriasis, according to the National Psoriasis Foundation. Between 10% and 30% of these patients will also develop psoriatic arthritis.
Early diagnosis of psoriatic arthritis (PsA) is critical for preventing joint damage, according to the American College of Rheumatology. However, Rebecca Haberman, MD, clinical instructor in the department of medicine, division of rheumatology at NYU Langone Health, said PsA often goes undiagnosed.
“PsA is a disease that has really just come into play over the last decade,” she told Healio Rheumatology. “It is a separate entity from rheumatoid arthritis. If someone has psoriasis — or even family members with psoriasis — and starts to develop aches and pains, it is important for that patient to have a full evaluation.”
Healio Rheumatology spoke with Haberman about the importance of recognizing and diagnosing PsA, as well as recent advances in treatment, the role of comorbidities in disease management and the need for a multidisciplinary approach to PsA.
Q: What recent advance s have been made in PsA treatment?
Haberman: The number of treatments that are approved for PsA has dramatically grown over the past few years. There are many treatments that target different chemical pathways in the body, all of which are implicated in causing PsA. Five years ago, we had two or three treatment options. Now we have seven or eight options and many more in the pipeline for not only existing targets, but also new targets and combinations of targets.
One problem that we face in PsA treatment is deciding which medications are best for which patients. It is often trial and error; we pick a medication based on each patient’s most pressing complaints while considering the adverse events associated with the medication. If the patient does not respond, we have to take them off of that medication and try a new one. The good news is that we have a lot of new treatments to choose from, even oral options such as apremilast (Otezla; Celgene) or tofacitinib (Xeljanz; Pfizer). Some patients feel more comfortable receiving pills before moving to injectables.
Q: Are there any safety concerns with current treatment s ?
Haberman: Each medication has its own safety profile that should be discussed with each individual patient. Some medications should not be used in the presence of certain comorbidities such as depression or heart failure. All of this should go into treatment decision-making.
Most of the biologic medications for PsA control the disease by tampering down the overactive immune system, which could make patients more susceptible to infection. Patients should be aware of this risk.
Q: How prevalent are psychiatric disorders/psychosocial disruption in patients with PsA? What is the rheumatologist's role in addressing such disorders?
Haberman: Unfortunately, these disorders are common in PsA. The disease is associated with stress and reduced quality of life, even unemployment and decreased productivity because people are in pain and it can hard for them to move.
It is estimated that up to 30% of patients with PsA have depression or anxiety. Recent studies have shown that depression and anxiety may even prevent patients from achieving complete remission from PsA. As a result, these patients may have more tender or swollen joints and could be in pain longer than those who do not have depression or anxiety. It is a huge problem in this population and something that not all rheumatologists feel equipped to address. It is very important for us to recognize these issues and ask probing questions, such as, “How are you feeling? How are you doing in your everyday life? How are you functioning? How are you getting along? Are you missing work? Are you having any trouble in your relationships?” Getting the whole picture of how the patient is doing will help rheumatologists make proper referrals to mental health professionals when that is deemed appropriate.
Q: What other comorbid conditions play a role in PsA?
Haberman: The most important comorbidities other than depression and anxiety are cardiovascular disease and metabolic diseases. Patients with PsA are at a higher risk for myocardial infarction (heart attacks) and stroke, even when accounting for other risk factors such as age and smoking status. This is because PsA is a disease of inflammation not just of the skin and joints, but all over the body, which increases the risk for these disorders. Patients with PsA also have higher rates of hypertension, high cholesterol and diabetes, all of which increase the risk for events such as myocardial infarction and stroke.
Another important comorbidity to point out is obesity because this is something that our patients can change. Patients who are obese are more likely to develop PsA and have worse outcomes. The medications may not work as well in patients who are obese. This may be because of difficulty absorbing the medication or due to the fact that obesity itself is inflammation. Therefore, the medication is trying to overcome even more inflammation in the body. Weight loss is key in disease control if patients are obese.
Rheumatologists should really be discussing all these conditions during regular patient visits. They should also consult with primary care doctors to make sure patients are being assessed for high cholesterol, high blood pressure and hemoglobin A1c. The key in PsA is prevention. We must be on top of these patients to make sure we are getting all of their medical conditions under control.
Q: What are the most significant unmet needs in PsA?
Haberman: One of the most significant unmet needs is recognizing and diagnosing PsA. Even in dermatology practices where patients with psoriasis are frequently treated, up to 20% of these patients have undiagnosed PsA. It is not diagnosed enough, which means that patients are not receiving early or adequate treatment. It is really important that we reach out to dermatologists as well as patients to inform them of the signs and symptoms of PsA, such as worsening fatigue and the development of joint pain, stiffness or joint swelling. The earlier we can diagnose and treat the disease, the better the outcomes are for patients. A delay in treatment as little as 6 months can worsen outcomes.
In patients who are diagnosed with PsA, the biggest unmet need is holistic care. These are patients who have inflammation everywhere, so they need to be treated everywhere. However, patients with multiple conditions usually receive siloed care. There needs to be a multidisciplinary care team that can help patients with PsA decipher everything that is going on with their health. This means not just the rheumatologist and dermatologist, but also the cardiologist, psychiatrist and physical therapist — even the nutritionist and sometimes the orthopedic surgeon and the ophthalmologist. We all need to work together to treat the patient as a whole.
American College of Rheumatology. Psoriatic Arthritis. https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Psoriatic-Arthritis. Accessed Aug. 14, 2019.
National Psoriasis Foundation. Statistics. https://www.psoriasis.org/content/statistics. Accessed Aug. 14, 2019.
Disclosure: Haberman reports no relevant financial disclosures.