EXAMINING THE CRUCIAL COALITION BETWEEN DERMATOLOGY AND RHEUMATOLOGY IN PSORIATIC ARTHRITIS
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1 EXAMINING THE CRUCIAL COALITION BETWEEN DERMATOLOGY AND RHEUMATOLOGY IN PSORIATIC ARTHRITIS ACTIVITY 1: EARLY COLLABORATION IN THE TREATMENT OF PSA Key Slides
2 COMMON COMORBIDITIES OF PSORIATIC DISEASE Psoriatic arthritis Depression Obstructive sleep apnea Uveitis NASH Cardiovascular disease Metabolic syndrome Hypertension Diabetes Dyslipidemia Obesity NASH = nonalcoholic steatohepatitis. Kimball AB, et al. J Am Acad Dermatol. 2008;58(6): ; Reich K. J Eur Acad Dermatol Venereol. 2012;26(Suppl 2):3-11; Carrascosa, et al. J Am Acad Dermatol. 2005;53(4):573; Roberts KK, et al. Aliment Pharmacol Ther. 2015;41(3):
3 TIPS FOR DIFFERENTIATION Finding Psoriatic arthritis Osteoarthritis Gout RA AS Psoriasis Nail dystrophy Enthesitis Less often Dactylitis Less often Peripheral disease Asymmetric Varies Asymmetric Symmetric - Axial disease + - Less often - + DIP involvement Morning stiffness >45 min Rheumatoid factor Minority of cases - - Majority of cases - RA = rheumatoid arthritis, AS = ankylosing spondylitis, DIP = distal interphalangeal.
4 CASPAR CRITERIA Criterion Test Points Current Psoriatic skin or scalp disease present today as judged by a qualified health professional 2 Psoriasis History A history of psoriasis that may be obtained from patient or qualified health professional 1 Family history A history of psoriasis in a first- or second-degree relative according to patient report 1 Nail changes Typical psoriatic nail dystrophy, including onycholysis, pitting, and hyperkeratosis, observed on current physical examination 1 1 Negative RF test By any method (except latex), according to local laboratory reference range Current Swelling of an entire digit 1 Dactylitis History A history of dactylitis recorded by a qualified health professional 1 Radiological evidence of juxta-articular new bone formation Ill-defined ossification near joint margins (excluding osteophyte formation) on plain X-ray of hand or foot Taylor W, et al. Arthritis Rheum. 2006;54(8): ; Coates LC, et al. Arthritis Rheum. 2012;64(10):
5 SCREENING QUESTIONNAIRES Tool Structure Psychometrics EARP epasq PASE PEST ToPAS 14 questions Self-administered 10 items + joint diagram Self-report 15 items Self-administered 5 items + joint diagram Self-administered 11 items + pictures/diagram Self-administered Sensitivity 85.2% Specificity 91.6% Sensitivity 97.6% Specificity 75% Sensitivity 82% Specificity 73% Sensitivity 97% Specificity 79% Sensitivity 86.8% Specificity 93.1% Husni ME, et al. J Am Acad Dermatol. 2007;57(4): ; Gladman DD, et al. Ann Rheum Dis. 2009;68(4): ; Ibrahim GH, et al. Clin Exp Rheumatol. 2009;27(3): ; Tinazzi I, et al. Rheumatology (Oxford). 2012;51(11): ; Khraishi M, et al. J Cutan Med Surg. 2011;15(3):
6 OVERARCHING PRINCIPLES OF EULAR AND GRAPPA GUIDELINES EULAR Psoriatic arthritis is a heterogeneous disease, which may require multidisciplinary treatment GRAPPA Ultimate goals of therapy: - Lowest possible disease activity - Optimize functional status and QoL and prevent structural damage - Minimize complications - Rheumatologists should primarily care for musculoskeletal manifestations - In significant skin involvement, rheumatologist and dermatologist should collaborate Assessment should consider all domains of disease: - Peripheral arthritis - Axial disease - Enthesitis - Dactylitis - Psoriasis - Nail disease - Pain, function, QoL Multidisciplinary and multispecialty assessment most beneficial Primary goal of treatment is to maximize QoL through symptom control, prevention of structural damage, and normalization of function Extra-articular manifestations and comorbidities should be taken into account when managing patients with psoriatic arthritis Clinical assessment includes patient-reported measures, thorough history and physical examination, supplemented by laboratory studies and imaging Comprehensive assessment of all relevant comorbidities should be performed
7 CASE: JEREMY 38-year-old bartender Overweight History of hypertension 9-year history of plaque psoriasis Primarily elbows and trunk BSA = 2% Managed by his primary care physician using topical agents Current medications Hydrochlorothiazide 25 mg daily Clobetasol propionate cream BSA = body surface area
8 CASE: JEREMY Noticed pain and stiffness in fingers of right hand ~1 year ago Progressed to left knee pain and stiffness after 6 months, at which point he told his primary care physician Primary care physician recommended ibuprofen; pain and swelling improved for a while After 6 months, both knees were involved Symptoms worsened and he could no longer work a full shift Primary care physician referred him to a rheumatologist
9 CASE: JEREMY Discussion Patient-specific treatment considerations Next steps
10 CASE, CONT D: JEREMY Rheumatologist obtains full history, conducts physical examination, orders laboratory studies (RF, ACPA, ESR/CRP) Jeremy is diagnosed with seronegative PsA with evidence of erosive disease on plain radiography Rheumatologist estimates moderate disease activity and prescribes methotrexate A biologic is added after 6 months based on persistent disease activity Joint symptoms resolve after 3 months However, skin lesions worsen during this time to 4% BSA, with increased itching and scaling RF = rheumatoid factor, ACPA = anti-citrullinated protein antibodies, ESR/CRP = erythrocyte sedimentation rate/c-reactive protein
11 CASE, CONT D: JEREMY Most important prognostic finding at initial diagnosis Evidence of erosive disease on plain radiography Implications for therapy Was initial regimen appropriate/sufficient? How should worsening skin symptoms be addressed?
12 CASE, CONT D: JEREMY Considerations for worsening skin symptoms Severity? Maintain current therapy and observe? Optimize topical therapy? Light therapy? Modify dose of methotrexate to target skin disease? Switch biologic to target skin disease?
13 CASE, CONT D: JEREMY Optimal strategy Consult with a dermatologist to help identify a strategy that could manage both skin and joint symptoms Dermatologist may modify topical treatment, consider phototherapy, or recommend changing biologic agent to one with greater efficacy for skin lesions Rheumatologist should maintain open communication and consult on any changes to therapy to ensure joint symptoms remain in remission (or low disease activity)
14 CASE, CONT D: JEREMY LATE DIAGNOSIS = EROSIVE DISEASE Jeremy had joint symptoms for over a year before seeing a rheumatologist and receiving effective treatment One important reason for frequent screening for PsA is the hypothesis that early intervention can limit progression of disease This concept underlies the T2T approach established in the treatment of RA and translated now to PsA T2T involves intensifying treatment until the target of remission or low disease activity is achieved Early diagnosis and routine assessment of disease activity are key components of this approach Coates LC, et al. BMC Musculoskelet Disord. 2013;14:101.
15 CONSIDERATIONS FOR T2T IN PSA How aggressively should PsA be treated? What is the target? Patient-specific factors/patient preferences must be considered
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