Perspective from Ellen M. Field, MD
Disclosures: This study was funded by Novartis. Ogdie reports consulting fees from Amgen, AbbVie, Bristol Myers Squibb, Celgene, Corrona, Gilead Sciences, Janssen, Eli Lilly & Co., Novartis, Pfizer and UCB; grant support from the NIH/National Institute of Arthritis and Musculoskeletal and Skin Diseases, the Rheumatology Research Foundation, National Psoriasis Foundation, Pfizer, Amgen and Novartis. Please see the study for all other authors’ relevant financial disclosures.
October 20, 2021
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'Build-up' of arthritis, axial symptom diagnoses often precede PsA diagnosis

Perspective from Ellen M. Field, MD
Disclosures: This study was funded by Novartis. Ogdie reports consulting fees from Amgen, AbbVie, Bristol Myers Squibb, Celgene, Corrona, Gilead Sciences, Janssen, Eli Lilly & Co., Novartis, Pfizer and UCB; grant support from the NIH/National Institute of Arthritis and Musculoskeletal and Skin Diseases, the Rheumatology Research Foundation, National Psoriasis Foundation, Pfizer, Amgen and Novartis. Please see the study for all other authors’ relevant financial disclosures.
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Diagnoses of arthritis, axial symptoms and tendonitis or enthesitis often increase over time before a patient is finally diagnosed with psoriatic arthritis, according to data published in Arthritis Research & Therapy.

The researchers added that, in the 6 years prior to diagnosis, patients with PsA tend to have an increased history of codes for osteoarthritis, rheumatoid arthritis and psoriasis — “suggestive of PsA symptom build-up” — compared with those without PsA.

Diagnoses of arthritis, axial symptoms and tendonitis or enthesitis often increase over time before a patient is finally diagnosed with PsA, according to data derived from Ogdie A, et al. Arthritis Res Ther. 2021;doi:10.1186/s13075-021-02628-2.

“A timely diagnosis of PsA is critical because a delay in diagnosis negatively impacts patient outcomes,” Alexis Ogdie, MD, MSCE, of the Perelman School of Medicine at the University of Pennsylvania, in Philadelphia, and colleagues wrote. “Unfortunately, diagnostic delay is common in PsA.”

“In a cross-sectional study of 203 participants with self-reported PsA in the USA, approximately one-third received their diagnosis within 6 months to 4 years, while another one-third had to wait for > 5 years,” they added. “These participants also consulted with numerous health care providers prior to receiving their diagnosis. A 6-month delay from PsA symptom onset to initial rheumatology consult may lead to joint erosion and damage. An increased awareness of the heterogeneity of PsA symptoms and diagnostic barriers may lead to a timely diagnosis.”

Alexis Ogdie, MD, MSCE
Alexis Ogdie

To analyze patient experience prior to a diagnosis of PsA and assess whether preceding health events may predict said diagnosis, Ogdie and colleagues conducted a retrospective cohort study of administrative claims data from Truven MarketScan. According to the researchers, MarketScan research databases include information on more than 263 million patients with commercial, Medicare supplemental and Medicaid coverage.

For their study, Ogdie and colleagues focused on the period from January 2006 to April 2019. They included a total of 13,661 adults with at least two PsA diagnoses — ICD-9-CM/ICD-10-CM — spaced at least 30 days apart, with at least 6 years of continuous enrollment prior to PsA diagnosis. These patients were matched 2:1 to a group of control individuals without PsA. The researchers examined diagnoses recorded prior to the PsA diagnosis, as well as the provider types that issued the diagnoses, all additionally stratified by the presence of psoriasis.

According to the researchers, patients with PsA demonstrated an increased history of coding for arthritis and dermatologic events, compared with those without PsA. These events included osteoarthritis — 48% in those with PsA versus 22% among controls — rheumatoid arthritis — 18% versus 2% — and psoriasis — 61% versus 2%. In addition, diagnoses of arthritis, axial symptoms, and tendonitis/enthesitis increased over time preceding an ultimate diagnosis of PsA. The researchers also noted a sharp rise in psoriasis diagnoses 6 months prior to a PsA diagnosis.

Consultations with a rheumatologist were more common immediately preceding a PsA diagnosis. Dermatologists were, in general, unlikely to code for arthritis and musculoskeletal issues, while rheumatologists were unlikely to code for psoriasis. General practitioners, meanwhile, tended to focus on axial and musculoskeletal symptoms. Among the examined PsA diagnoses, 40% were made by rheumatologists, 22% were made by general practitioners and 7% were made by dermatologists.

“An overall prevalence of skin and nonspecific musculoskeletal manifestations, in addition to consultations with various types of health care providers, may collectively serve as predictors of PsA,” Ogdie and colleagues wrote. “Greater awareness of patterns or trends of health events as seen in our study may alert general practitioners and other health care providers in primary care settings to suspect a diagnosis of PsA among their patients.”

“As PsA is associated with considerable health care costs, the number of non-PsA diagnoses, potentially suggestive of misdiagnoses, and health care visits across different types of providers suggest the increased utilization of health care resources,” they added. “The clinical and economic burden associated with PsA will most likely impact disease management and medical and pharmacy policy formulation. Increased awareness and understanding of diagnostic barriers may lead to timelier diagnosis, cost savings, and appropriate intervention to improve outcomes.”