Wednesday, December 6, 2023
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Consultant Rheumatologist
President
Association of Women in Rheumatology
New York, New York
This activity has been peer reviewed and the reviewer has no relevant financial relationships.
This activity is intended for rheumatologists, primary care physicians, dermatologists, and other clinicians who provide care to patients with PsA.
The goal of this activity is for learners to be better able to incorporate novel therapies into personalized treatment strategies for active PsA.
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Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.
Consultant Rheumatologist
President
Association of Women in Rheumatology
New York, New York
This activity has been peer reviewed and the reviewer has no relevant financial relationships.
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Dr Jenner: Hi Jessica, good to see you. How are you?
Jessica: Hi Dr Jenner. I'm good, thank you.
Dr Jenner: Tell me about how your psoriasis and arthritis are doing.
Jessica: Well, there's this. And my elbows look awful. I've pretty much given up on short sleeves.
Dr Jenner: Hmm. So your psoriasis is definitely not where we would want it... Hey, that's a great manicure!
Jessica: Oh, thank you! This company makes great stuff.
Dr Jenner: Do you mind if I ask how your nails look under there?
Jessica: They've been kind of gross lately. I looked it up, and I think it's a fungus. So I just cover it up with tips.
Dr Jenner: It seems like you're having a hard time with that.
Jessica: Yeah -- and, I mean, this feels really shallow, but we're back in the office now and everyone is so fashionable and perfect all the time -- and I just feel so disgusting standing next to them sometimes.
Dr Jenner: I don't think that's shallow -- self-image is important. Tell me about your joints.
Jessica: The pain and swelling can make the day-to-day stuff frustrating. Even little things, like struggling to put on this necklace by myself because my fingers are swollen and stiff, especially in the mornings.
Dr Jenner: And what about pain anywhere else?
Jessica: Actually my back has been bothering me lately, especially when I first get out of bed. The stiffness is really noticeable when I'm trying to get my 3-year-old ready for daycare. It's harder to pick him up and run after him. But it's not as bad as my day goes on.
Dr Jenner: Do you ever take anything for the back pain?
Jessica: I've noticed ibuprofen helps, but I try not to take it too much. I mean, it's probably our mattress. It's old and I should really buy a new one. Just one more thing I need to do... I just... I'm tired...
Dr Jenner: I understand, Jessica. I know this is a lot to deal with.
Jessica: I just don't get why all of this is happening. Nothing I take seems to work. Methotrexate made me feel like garbage, and now this medication isn't working anymore. I'm sorry. I -- I'm just frustrated.
Dr Jenner: No need to apologize. It makes sense that you feel this way.
Jessica: I guess I just worry nothing is going to work.
Dr Jenner: Many of our medications do work well for a while, but sometimes they start to fail patients. The good thing is that we have lots of different therapies that we can still try. So you have choices -- we just need to find the right fit.
Jessica: I guess so.
Dr Jenner: I just want to ask you a few more questions about how you're feeling, do an exam, and then we can discuss next steps for your treatment.
Hello, I'm Dr Grace Wright, consultant rheumatologist in New York and president of the Association of Women in Rheumatology. Welcome to this program titled "Hitting the Target in Psoriatic Arthritis Management." As we just saw in this last scene, Jessica's PsA is no longer well controlled on her tumor necrosis factor (TNF) inhibitor, and she's experiencing a substantial negative impact on her quality of life (QOL). PsA can impose a heavy burden on patients and can affect them both physically and emotionally.
PsA, particularly in its more severe forms, can tremendously impact patients' QOL, can limit their activities daily and also negatively impact work productivity, as well as increase the risk of depression and anxiety. As we have just heard, Jessica's symptoms are impacting her self-image, childcare, and everyday activities such as getting dressed for work. She's experiencing symptoms across multiple domains of PsA, including her skin, nails, joints, and she also has axial disease and dactylitis.
This is common in patients with PsA, and so it is important to select a therapy that will target as many domains as possible with the aim of minimizing disease activity, reducing symptoms, and improving QOL. We now have several targeted therapies available for our patients. However, despite this, treating to target can be challenging because of the heterogeneity of disease presentation and treatments. Some treatments may be more effective in targeting certain aspects of a patient's disease. In patients with multi-domain involvement, some aspects of a patient's disease may respond well to treatment, while the same therapy may not improve or can worsen another aspect of the disease.
The 2021 Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) treatment recommendations recognize this and provide domain-focused recommendations for treatment selection. They also recommend assessing disease activity in each of the domains, and taking into consideration comorbidities, previous therapies, and patient preference. The 6 domain groups they focus on include peripheral arthritis, axial disease, enthesitis, dactylitis, skin psoriasis, and nail psoriasis. The recommendations also cover comorbidities with a potential influence on treatment, which are categorized into PsA-related conditions, inflammatory bowel disease (IBD) and uveitis, as well as other comorbidities. The authors recommend choosing a therapy that will ideally address all active disease domains using a shared decision-making (SDM) approach.
Based on the patient visit we just observed, it is clear that Jessica is unhappy with her current treatment and is distressed by the progression of her disease. Now, let's return to our clinic and see what decisions are made.
Dr Jenner: Jessica, is there anything else health-wise I should know before we talk about next steps?
Jessica: I don't think so... Uh, actually, this is embarrassing but -- I've been having some "tummy trouble." Like bloating and sometimes diarrhea.
Dr Jenner: Are you noticing any blood?
Jessica: A little bit. At first, I thought my hemorrhoids from after I gave birth were back, but I don't think it' that.
Dr Jenner: Any cramping?
Jessica: I'm not sure. My period cramps seem a little worse.
Dr Jenner: Hmm. I'm going to refer you to a gastroenterologist -- we want to make sure nothing else is going on.
Jessica: Okay.
Dr Jenner: Alright, let's talk about treatment. There are a few different things we can try. First of all, there are other TNF inhibitors. I know that adalimumab hasn't worked for you so far, but everyone responds differently, so we could try a different one.
Jessica: I feel like I'd rather try something different, if that's an option.
Dr Jenner: Okay, we can definitely talk about trying a new class of biologic agents. These work by blocking other parts of your immune system to fight the inflammation. Before I go into these, it would be helpful for me to know how you feel about the injections.
Jessica: They're fine. I mean, I'm kind of used to it at this point. It' not my first choice, and I'd probably prefer a pill, but I'm willing to deal with the needles if the meds will actually work.
Dr Jenner: Okay, that is good to know. So given what you've told me today, we have the class of interleukin (or IL)-12/23 inhibitors and IL-23 inhibitors. These work well in the joints, skin, and nails. IL-17 inhibitors are another class, and these can also work well in the skin, nails, joints, and your spinal symptoms. These are all injectables. There is also another class, which is an oral drug that you take every day, called Janus kinase (or JAK) inhibitors. These also work well in the skin, nails, joints, and back.
Jessica: Oh wow, those are lot of options!
Dr Jenner: I'd also like to review some of the safety information for these options before we make any decisions.
Jessica: Okay.
Dr Wright: As we just heard, there are a number of different classes of medications available for Jessica that are efficacious. She can certainly switch to another TNF inhibitor after failing her first one. TNF inhibitors target all the domains of PsA. IL-17 inhibitors are also a good option for targeting all the domains. However, given Jessica's gastrointestinal (GI) symptoms, it may be best to confirm the diagnosis before starting with one of these agents. The IL-23 and IL-12/23 inhibitors, as well as phosphodiesterase type 4 (PDE4) inhibitors, have shown efficacy in all domains except for axial disease. And then there are 2 JAK inhibitors, which have also shown efficacy in all the domains of PsA.
To clarify, only 1 agent in this list has been studied specifically to assess axial PsA, and that was secukinumab, and it demonstrated significant improvement in signs and symptoms. Other agents have demonstrated efficacy in radiographic and nonradiographic axial spondyloarthritis. And so recommendation for these agents are based on evidence extrapolated from these studies. IL-12/23 and IL-23 inhibitors did not demonstrate efficacy in ankylosing spondylitis. However, post-hoc analyses have suggested possible efficacy.
Given Jessica's presentation, skin, nails, axial disease, dactylitis, and joints, failure of a TNF inhibitor, possible IBD, and preference of oral route of administration, a JAK inhibitor may in fact be a good choice for her at this time. When starting a JAK it is important to review safety concerns individualized for that person, which includes their age, smoking history, and the risks of cardiovascular disease, thrombosis, malignancy, and infections. When deciding on treatment, it is helpful to offer information about available agents to the patient, including efficacy and safety of the agent, as well as convenience, time to see results, adverse effects, and insurance coverage. Providing patients with this information allows them to participate in the treatment selection. And asking patients for their preferences and incorporating a SDM strategy in the treatment selection can improve patient satisfaction and increase the likelihood of treatment adherence. The 2021 GRAPPA recommendations also emphasize the importance of reviewing treatment options with patients and taking into account their preferences. Let's return to the visit and see what happens next.
Dr Jenner: Okay, so I'll send over a prescription to your pharmacy today. Now, although our priority right now is to find a treatment to quickly alleviate your symptoms, I also want to talk to you about things you can do in your life to help with your psoriatic arthritis, such as exercise.
Jessica: But won't that make my pain worse?
Dr Jenner: That is a common misconception, but physical activity can actually decrease your pain and stiffness, make you stronger, and just make you feel better overall. And importantly, it can improve your cardiovascular health. Now, I know you have your hands full with your little guy and work and just life, so I know it's not easy. But if you can squeeze in 1 or 2 days a week to start, that would still be helpful.
Jessica: Okay. I mean, I've been wanting to be more physically active recently. I used to go to the gym a lot back in the day, and I do miss "that high" I would feel when I' leave the gym.
Dr Jenner: It will definitely help with your fatigue, and you'll see that your energy levels will be higher. Even making small changes, like standing up or taking short walking breaks after 30 minutes of sitting at your desk.
Jessica: Okay. I can try setting a timer on my work calendar to remind me to do that.
Dr Jenner: Great! I can provide a referral to a physical therapist who can guide you on starting an appropriate exercise program. And then I'd like to see you in a few weeks, and let' see how you respond to the new treatment. Of course, please feel free to reach out to me or my office if you have any questions or concerns.
Jessica: Thank you, Dr Jenner!
Dr Wright: In addition to skin and joint manifestations, PsA is associated with several comorbidities, including cardiovascular disease, metabolic syndrome, diabetes, mood disorders such as depression and anxiety, fatty liver disease, osteoporosis, and fibromyalgia, and associated conditions mentioned earlier, uveitis and IBD. These chronic conditions can influence treatment choice, response to treatment, as well as morbidity and mortality. Therefore, screening for these disorders is an important part of patient management.
We know that the risk of cardiovascular disease is greater in patients with PsA compared with the general population. Our patient, Jessica, is overweight and so it's important to bring up lifestyle changes that she can incorporate to improve her cardiovascular outcomes. This includes a focus on wellness, diet, exercise, and mental health, which is respectful of her social and cultural preferences.
In following patients like Jessica it's important to see them back after a few weeks of therapy, both to assess her response as well as any adverse outcomes. Measures that we can use to assess her overall disease control include things like the RAPID3, MDA, looking at minimal disease activity, measuring the points that are important for her, the enthesitis, the dactylitis and then looking again at her overall health.
Thank you for joining me today in the Medscape Clinic. I hope you found the information presented here valuable to your practice. Please continue on to answer the questions that follow and complete the evaluation.
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