Activity Transcript

Philip Mease, MD: Hello, I'm Dr Philip Mease, director of rheumatology research at Swedish Medical Center, Providence-St. Joseph Health, and clinical professor at the University of Washington School of Medicine in Seattle. Welcome to this program titled “Patient-Centric Case Discussion in Psoriatic Disease: Focus on Psoriatic Arthritis.”

Joining me today are April Armstrong, professor of dermatology and associate dean for clinical research at the University of Southern California in Los Angeles; Chris Lindsay, GRAPPA patient research partner; and Evan Siegel, assistant clinical professor of medicine at Georgetown University School of Medicine and medical director of arthritis and rehabilitation therapy services at Arthritis and Rheumatism Associates in Rockville, Maryland. Welcome.

Psoriatic arthritis is a heterogeneous inflammatory disease that can cause permanent damage to both peripheral and axial joints. It is also the most common comorbidity of psoriasis, occurring in up to 30% of patients with that disease. Early recognition, diagnosis, and an intervention is important to prevent development of permanent joint damage and to reduce patient burden. Today, we will discuss the importance of recognizing psoriatic arthritis in a psoriasis patient, as well as assessing disease activity and treating to target.

Let's start with a case. We have a 44-year-old male patient with a history of psoriasis presenting to dermatology clinic for follow up. He's had psoriasis for about 10 years. During his intake, when asked if he was still taking the same medications and if he had any new ones, he mentions that he's been taking ibuprofen for pain. And when asked if he had any other medical concerns that the dermatologist needed to know about, he commented that he was recently diagnosed with recurrent tennis elbow at an urgent care facility. And then when further asked, "Do you have joint pain or other forms of musculoskeletal pain to tell the dermatologist about," he comments that it's been hard for him to walk from the parking lot into the office and difficulty with buttoning his shirt. He also finds that he's more tired than usual, but he's been working longer hours so he considered it probably related to that. So, April, tell me, how would you go about assessing this patient and what would you do to further ascertain whether he might have psoriatic arthritis in addition to the psoriasis that you've been following him for?

April Armstrong, MD, MPH: There are a few different questions that I would like to probe further. Number 1 is that because psoriatic arthritis, as you said, is more common in patients with psoriasis, I would want to know if there's a family history of psoriatic arthritis or other types of arthritis. I also want to know if the patient feels that his joints are stiffer in the morning when he first wakes up.

And then importantly, I want to know if a patient has experienced any swollen joints or has seen any joints swell for no reason at all. A few other questions that I would typically derive from what's called the Psoriasis Epidemiology Screening Tool (PEST) questionnaire, which is a questionnaire that can be used in dermatology clinics, for example, for patients to complete while they're waiting, including things such as if they have pain in the heel. And importantly, I also want to ask a little bit about back pain because that can be a manifestation in our patients.

In terms of examination, of course, I'm going to examine the skin for psoriasis as a dermatologist, but I also want to pay attention to nail disease. And the reason for this is that nail disease oftentimes can occur concurrently with psoriatic arthritis. For joint exam, I will say I tend to do a very limited joint exam and I will say most of the tips I have learned are from you, as well as from Dr Siegel here and probably applying some pressure on the joints that he may complain about to see if there's tenderness that I can elicit.

Dr Mease: So Chris, what were your experiences in the dermatologist offices that you were attending prior to diagnosis of psoriatic arthritis? And tell us a little bit about that journey.

Christine Lindsay, BSc, PharmD: So my experience with the diagnosis of psoriasis was one that really caught me off guard. It was a stressful time in my work. And to have a diagnosis of psoriasis on my face, my ankles, my knees, my elbows. It caught me off guard, but was easily treatable and probably considered more mild to moderate. What I wished I had understood a little bit more was the family history, because I went to talk to my sister only to find out everyone in our family had psoriasis. And I had no idea that that's what I was going to expect. So for me, it was a difficult time walking and having been diagnosed with a sprained ankle that I went to physical therapy for and I wasn't getting any better and just something in the back of my mind said, "You know what? I think I probably need to have a conversation and maybe go see a rheumatologist. This might be something more, I had this diagnosis in the past."

Dr Mease: Yes. That's a very common sequence that you've just described. April, what did you assess when you were seeing the patient in your clinic?

Dr Armstrong: We found the patient to have body surface area (BSA) of psoriasis around 5%. And upon further examination, we saw nail changes, and the nail changes involve pitting as well as onycholysis, which is the lifting of the nail plate from the nail bed. Both of these changes are typical changes seen in psoriatic nail disease, where psoriasis affects both the nail matrix as well as the nail bed.

And, in addition to that, the patient was found to have some scalp disease. In terms of the joint assessment in our dermatology office, we found that this patient had 3 swollen joints in the hands, mostly in the PIP joints, and a slightly swollen left knee. There was also some tenderness in the Achilles tendon insertion point, as well as in the lateral epicondyle. So several things here. And we do feel that this is a good opportunity for us to refer the patient to rheumatology for further evaluation.

Dr Mease: So you're a dermatologist with an honorary degree in rheumatology, it sounds like, with some skill here in doing physical exam, including finding not only evidence of arthritis, but enthesitis where tendons or ligaments insert into bone which is fairly unique for psoriatic arthritis. So you were able hopefully to get the patient quickly into your friendly rheumatologist down the hall or across the country. And so, Evan, tell us what happened when the patient got to you.

Evan Siegel, MD: All right. Well, thank you, Philip. When a patient comes in to see me for a new diagnosis of potential psoriatic arthritis, really a fairly comprehensive evaluation, I take a very careful history. I like to know about the timing initially of the psoriasis, when they developed psoriasis, when they developed their arthritis. I like to talk to them about the joints that are involved so they understand the areas I'm going to focus on in my exam, but also to understand how that affects their functionality, because that's really what's important to the patient: how their function is impacted.

I like to ask them about whether there's a significant amount of tendonitis and enthesitis, and whether they've had a history of significant tendonitis or tennis elbow in the past. I'll then query them about other domains, certainly dactylitis. We ask patients if they've ever had a completely swollen finger or toe. I query about inflammatory back pain, back pain that's better with activity, worse with rest, nighttime pain, onset before age 40, a number of other features.

I do like to ask them about their nail involvement because that has been associated as a predictive factor for psoriatic arthritis, and then query them also about other manifestations like inflammatory bowel disease or uveitis that can be associated. So it's a really very comprehensive history, including family history, not only of psoriasis or psoriatic arthritis, but whether there is a family history of ulcerative colitis or Crohn's disease. Also important because it may impact the medications that we choose, I ask about a smoking history and I ask about their alcohol history.

The exam, I like to do a good comprehensive general medical exam when I see patients for the first time, but then really do a full joint exam, looking particularly at the hands and feet, making sure that they have their shoes off and that I'm examining all toe joints as well, and looking at tendon insertion sites. And I particularly like to make sure I've touched on all the things included in something called the Leeds Enthesitis Index, the 6 sites: lateral epicondyles, medial condyles of the knee and the Achilles tendon insertion. While I’m there, I usually poke on the area where the plantar fascia inserts.

And then we may do some targeted x-rays. I almost always like to look at the hands with x-ray, especially looking for any periarticular calcifications, which falls as one of the CASPAR criteria measures. And then I'll do x-rays in areas that may be symptomatic in other joints, or look at the sacroiliac joints if they have had inflammatory back pain. From a laboratory perspective, generally we'll do general chemistry panel and a CBC, but also a sed rate, C-reactive protein. If the patients have had an inflammatory back pain, I may check in HLA-B27. And if I'm thinking that they do have active psoriatic arthritis, I may initially get a QuantiFERON and hepatitis profile in advance of prescribing medications that may need those as a baseline.

Dr Mease: I could tell why you are so popular as a physician, Evan, because that's quite a comprehensive evaluation and taking the time that you do really builds trust. And what are the key differential diagnoses that you find in evaluating these patients? Obviously this patient that April has just sent you may well have psoriatic arthritis, but are there any other conditions that you're distinctly ruling out?

Dr Siegel: Well, certainly osteoarthritis (OA). Psoriatic arthritis often affects the DIP joints, but so can osteoarthritis, and particularly vexing differential is inflammatory osteoarthritis. But for OA, I'm really looking really for more bony changes and not synovitis or joint swelling. Rheumatoid arthritis is certainly in the differential diagnosis, usually much more of a symmetric polyarthritis. Gout is sometimes a tricky one. Patients with psoriasis often will have an elevated serum uric acid from extensive skin turnover. But gout generally is an episodic type of arthritis, an arthritis that has acute sudden onset of swelling and pain, and then dissipates and the joint goes back pretty much completely to normal -- not so in psoriatic arthritis.

Dr Mease: Thank you. And there's also a classification criteria that's been developed for psoriatic arthritis. Are there ways in which you utilize the CASPAR criteria?

Dr Siegel: Yes, the CASPAR criteria were set up as classification criteria, not diagnostic criteria, but I must admit I keep them in the back of my mind whenever I'm trying to make a diagnosis of psoriatic arthritis. So yes, and probably the most important part I think of the CASPAR criteria is the stem entry criteria, the presence of active inflammatory musculoskeletal involvement. So that's arthritis, enthesitis, and spondylitis.

Dr Mease: And as well, and you've mentioned this already, important associated conditions include the potential for uveitis, inflammation of the eye, or inflammatory bowel disease, either Crohn's or ulcerative colitis. These conditions are part of the spectrum that we see that are associated genetically with psoriatic arthritis and psoriasis, and so important to query patients about the potential history of this and to educate them about this. April, what are some of the comorbidities that are common in psoriasis and psoriatic arthritis that you find yourself wanting to educate your patients about and make sure they're being attended to?

Dr Armstrong: For patients with psoriasis, especially those with more extensive disease, as well as patients with psoriatic arthritis, we tend to see higher incidence as well as higher prevalence of these cardiovascular risk factors. Things such as diabetes, dyslipidemia, hypertension, metabolic syndrome are all increased in our psoriasis patients. And the thought is that the systemic inflammation that underlies psoriasis as well as psoriatic arthritis can contribute to these cardiovascular comorbidities. In addition to that, I let them know that if these cardio-metabolic risk factors are not well managed, then the likelihood of them experiencing cardiovascular events, such as stroke or heart attacks, can be significantly increased. In addition to that, liver disease, especially non-alcoholic fatty liver disease, is increased in patients with psoriasis and psoriatic arthritis. And this is relevant also when we think about therapies for our psoriatic disease population.

And then finally, our patients with psoriasis or psoriatic arthritis have an increased rate of depression. We oftentimes think that the patient is depressed because they are looking at their skin disease and they feel embarrassed about it. And certainly that's part of it, but we now have new understanding in this particular area that the increased inflammatory cascade in these patients, that's going on systemically, can actually lead to, for example, a leakier blood-brain barrier, therefore more inflammatory cells, that can actually be at increased levels going in across a blood-brain barrier and in our central nervous system. So there's not only a psychological aspect of the impact of psoriasis, for example, in the relationship to depression, but now we are understanding more regarding the biological underpinnings of depression in our patient population.

Dr Mease: So a couple of additional comments about comorbidities include the fact that osteoporosis is more common in patients with psoriasis and psoriatic arthritis and fibromyalgia, which is an augmented pain sensitization phenomenon sometimes called central sensitization syndrome or nociplastic pain. And we see this anywhere from 15% to 20% of our patients with chronic autoimmune inflammatory diseases, such as PsA and rheumatoid arthritis and so on. So these are ones to attend to.

Chris, I'm curious. Hearing all this and thinking about your own situation, tell us about the weaving together of the matrix of people that has been helping you with dealing with different aspects of your condition. You had mentioned that you had hyperlipidemia. I'm curious how all of this is woven together.

Ms Lindsay: For me, and speaking from my perspective, knowing the risk of cardiovascular disease was going to be higher made me want to take action a little sooner. I had a more serious conversation with my internal medicine doctor and my OB/GYN who was also pushing me to go on a statin, right? That diet and exercise while I really wanted it to work, wasn't working. And that with this risk, I needed to probably take action sooner. And while that maybe scares folks, I really tried to listen to what the experts were telling me about all of these different risk factors. So trying to eat more healthy, trying to keep my weight down, trying not to drink too much on a stressful day, right? Those are challenges that all patients face, having a team of doctors who continually back each other up as all of you do, is what's really important for a patient. So they hear it from multiple sources. I think that that has a bigger impact for them.

Dr Mease: And one comment I would make is using the word “sequencing.” So I don't try to hit a patient with all of this information on the first visit. I sort of stagger it over time because just getting the initial diagnosis of psoriasis is a big deal, then subsequently the diagnosis of psoriatic arthritis is a big deal. And then having, "Oh, you mean, I might die younger than usual because of my cardiovascular risk?" So these are things that all should be brought up and make sure that your clinicians are dealing with them, but not overwhelming the patient.

Evan, what did you find when you actually saw the patient in your clinic? You've described how you go about your general approach, but what did this specific patient show?

Dr Siegel: So for this patient, first of all, we were able to nicely confirm what the dermatologist had found. So he did in fact, have 3 swollen joints in the hands, including 1 DIP joint, and a couple of PIP joints. He also had dactylitis on exam, so he had a completely swollen toe. And that was inflammatory dactylitis, so is important to know that there can be inflammatory dactylitis and later on more burnt out non-inflammatory dactylitis. But that tender completely swollen digit is really quite inflammatory and, in a sense, an urgent call for treatment. He had a slightly swollen left knee. Did turn out to have a tender Achilles tendon insertion, and 1 lateral epicondyle.

He did in fact, on questioning, have symptoms of inflammatory back pain. So he was waking up in the middle of the night with severe pain, and he was stiff in the morning, difficulty moving for about 45 minutes to an hour. He had significant skin and nail findings. He had about 5% body surface area. It's important to remember for the rheumatologist that 1 palm equals 1% body surface area. And so it's important for us as rheumatologists to also continue to follow the amount of body surface area that's involved and make sure that that's improving over time. He had involvement of the scalp, he had nail changes with pitting and onycholysis, separation of the nail from the nail bed.

Fortunately on imaging, he did not have much in the way of erosions thus far. Laboratories showed that he did have an elevated ESR. Remember that only about 60% of patients with psoriatic arthritis will have an elevated ESR, but he did, showing that there was significant inflammation. And it turned out in talking about comorbidities that he was a current smoker, and that may play a role in some of our thoughts about what may or may not be a good therapy. But also smoking may in fact have issues with efficacy of some of our therapies and certainly feeds into the comorbidity of cardiovascular disease.

Dr Mease: So he's got active disease that we consider to be psoriatic arthritis, and so what approaches do we have for treatment? So fortunately at the current time, we have a smorgasbord of highly effective options. But to start with, it's important to remember that each individual patient in front of you is unique.

They may have different combinations of the various clinical domains that we've referred to, spine on the one hand, peripheral arthritis on the other, skin disease. And so we have to think about the therapies that we're choosing and whether they work well in each of these clinical domains. And of course there are many nonpharmacological approaches that we've already alluded to that the patient may benefit from including physical therapy, smoking cessation, as Evan was just referring to, weight loss is a big one for patients who are obese because we know that their symptoms can improve simply with weight loss, and so on.

Typically, the patient prior to getting to a rheumatologist has tried multiple nonsteroidal anti-inflammatories, maybe had some steroid injections, but they're here because these have been inadequate. So there are a number of different pharmacological mechanisms of action that have proven to be quite helpful, including some of the oral older medications, such as methotrexate, the TNF inhibitor class, which has been our really working course over the last 2 decades of which there are 5 members of that particular class. IL-12/23 inhibitor, interleukin 17 inhibitors, which there are 2 currently, a CTLA4 immunoglobulin known as abatacept, Janus kinase inhibitors which are oral medications, including tofacitinib and upadacitinib, and then an interleukin 23 inhibitor guselkumab, as well as risankizumab. So we've got quite a large repertoire of medications to potentially choose from.

The GRAPPA treatment guidelines are useful for us. GRAPPA is an organization that's devoted to research and education about psoriasis and psoriatic arthritis. It stands not only for an after dinner liqueur, but also Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. I can tell you more about the origins of the name, but I'll leave that for another time. But the key point about their treatment recommendations are that they divide the clinical domains into different categories, peripheral arthritis, spine disease, enthesitis, dactylitis, skin disease, nail disease, and they identify which are the effective therapies for each of those clinical domains. So for example, if we're talking about enthesitis where there's not too much evidence for benefit from some of the older traditional oral medications, then we may want to move sooner to a biologic or a targeted synthetic DMARD a little bit earlier, for example.

And certainly skin disease may require a whole different set of approaches and close conversation with the dermatologist about how best to manage that. So what we do is we sort of determine which are the most active clinical domains in front of us. Think of it like sitting in an orchestra performance. And at times all of the sections of the orchestra are playing fortissimo and you need to really go at them with drugs that affect all of these beneficially. But at other times it might just be the flute section that's playing and so we want to focus on that. For example, if the patient is doing well in all regards except for their spine, then we need to think about what is going to be the most effective therapy for the spine. So I won't get into the specific details that you can refer to, but just be it known that most of the biologic agents and the targeted synthetic DMARDs, these newer medicines such as apremilast or the JAK inhibitor class, can be highly effective in multiple domains. And that's the good news for our patients, so that we can try to get them into a state of low disease activity or remission, which is really our goal in treatment.

So I'd like to turn back to the panel and ask first, Evan, how do you end up talking about these treatment options with your patients?

Dr Siegel: I think it's overwhelming for a patient to hear about all the different treatment options that there are. We have so many now. In the old days, there weren't as many. So I try to think about the domains that have been most significant for the patient. At this point, I know that after the exam and the history, then I think about their comorbidities, and which things I would eliminate immediately because of their comorbidities. And that helps me to limit the choices that I'm going to present. And then it comes down in part to patient preference. So I do present to them what would be efficacious and what would not be problematic with their particular comorbidities, and then present the options between injectable or infusible or oral therapies. Sometimes there's a big preference from a patient for one or another and if we can accommodate that, I try to. Of course, insurance plays a big role too, and I have to talk to them about what may or may not be covered by their insurance. So I think once we've had that discussion, patients can help to make the decision and I think we try to come to that together.

Dr Mease: And of course, you're talking to them about safety concerns throughout and some of the safety and tolerability profiles. Chris, what was it like for you regarding the balance between talking about efficacy of these potential therapies in the context of their relative safety and tolerability. Did clinicians really put in appropriate context the safety concerns?

Ms Lindsay: Absolutely. So I loved the conversations about treatment and the choices that we were going to make. I was very driven and I was a very specific patient with goals. I had goals of what I needed to achieve. I personally needed to keep working and I needed a treatment that would help me keep working. And so going into that with my physician and rheumatologist as a partner and that led to this shared decision-making process that we all talk about, right? I had my goals, then we talked about what the risk-benefit profile was and what I was willing to accept or not accept. I actually wanted my doctor to help me choose at that point, or at least narrow it down a little bit as to where we go first, second, and third. And the comfort I had was that my doctor always had something next and that's the beauty of having multiple therapeutic options was they would say, "Let's try this. If it doesn't work, I got you, we'll try something else."

Dr Mease: But also the phenomenon that therapies may work great for sometimes a long period of time, but oftentimes then will lose effect. And so it's nice to have something to switch to, a different mechanism of action, for example. And April you've alluded to this earlier, the comorbidities that patients have. How do you weave that into the discussion and choices that you make?

Dr Armstrong: I think number 1 is liver disease, which is quite prevalent in this patient population. So especially with patients with fatty liver disease and those with viral hepatitis, we want to avoid medications that can be more toxic or injurious to the liver: oral therapies, such as methotrexate for example. For patients with active or treated viral hepatitis B, we still want to try to avoid TNF inhibitors in those patients. For patients who may have uveitis or inflammatory bowel disease on the other hand, TNF inhibitors can be quite helpful because they can treat oftentimes both of these comorbidities in addition to patients' psoriatic disease. For patients with a personal history of inflammatory bowel disease, we want to typically avoid IL-17 inhibitors in these patients to avoid exacerbation of IBD.

Dr Mease: So now we've gone through with the patient the various treatment options, both efficacy and safety potential, and have chosen therapies and we're now monitoring for benefit, as well as any safety issues that may arise. So Evan, I'm curious about how you go about checking on patients when they come in for follow up visits, what instruments or measures you may use, and then also how you communicate that with the dermatologists that you're working closely with who's simultaneously tracking skin and nail findings.

Dr Siegel: Phil, I really try to continue to monitor all domains as patients come in just as I did at the beginning to make sure that all of the domains are actually responding to the therapy. And I find really one of the best ways to do that is to think about MDA or minimal disease activity and the various components of it. It helps me to focus on whether patients are truly improving in multiple domains.

Dr Mease: I really like the minimal disease activity as well. It's pretty quick and easy to do in the clinic. We are doing a joint assessment anyway, so tender and swollen joint count, a quick assessment of skin disease with the hand print representing 1% of body service area. So if it's less than 3, that's a threshold that we want patients to achieve. There's a question on pain, how they're doing globally. Probably the hardest thing is the HAQ score, the function measure. And in Seattle, what I asked patients about is were they able to go hiking last weekend up the mountain, or were they able to go to their soccer game. Very active patients out here. But they love the kind of quantitative metric of looking at the various domains, including enthesitis for example, skin, joints, and then seeing if they crossed into a low disease threshold and then trying to stay there. It's really very neat to watch patients get into this and really aim for that and report if they're not doing well in some areas. And it turns out that there's a lot of cross between the RAPID-3, which many clinicians use, and the MDA, just to add in quick assessment of skin, as well as enthesitis, for example.

Chris, how has it been for you in terms of having monitoring of your skin and musculoskeletal elements as well as other factors in the clinic?

Ms Lindsay: So I love having a score to measure as well. I do think there's a little bit of healthy competition in many patients, right? We want to improve. I also think sometimes we want to understand what aspect of our disease is driving how we're feeling. So we may come in feeling just not sort of right, but we can't put our finger on it. You all do work, your wonders, you do your assessment, you have a score and you can sort of say it's this aspect of your disease that's probably making you feel worse, and if we work on this, we can help you get better. And that's always reassuring as well to know that.

Dr Mease: It hopefully reinforces the trust that you have in your clinicians to be doing this comprehensive assessment and then talking about it and sharing with you, “Okay, here's where we are and how shall we go forward and what is important to you?”

We've learned that psoriatic arthritis is a complex disease with many different clinical domains that may be active at any given time. And it's important to address those and query the patient, examine the patient, do appropriate laboratory imaging to assess the domains and then treat appropriately. There are also a number of associated conditions and comorbidities that may be present. And so working closely with other specialists, whether it be obviously the derm and rheum specialties, but also gastroenterology, ophthalmology, cardiovascular disease specialists, as well as the primary care clinician and physical therapist. So it really does take a village and we can get our patients with psoriatic arthritis to a better place. The therapies that we have are really good in their ability to bring inflammation down and take away many of the symptoms that are plaguing patients and impairing their ability to function and have good quality of life ranging from pain to fatigue, to sleep disturbance, to the various issues around functional capacity.

So I want to thank the panelists, Evan Siegel, April Armstrong, Chris Lindsay. It's been a wonderful time. Thank you very much. And thank you for participating in this activity. Please continue on to answer the questions that follow and complete the evaluation.

This is a verbatim transcript and has not been copyedited.