Cross-specialty collaboration, referrals crucial during ‘window’ to prevent, diagnose PsA
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While novel drugs are changing the game in psoriatic arthritis, early diagnosis and interdisciplinary management remain keys to successful outcomes, according to a speaker at the Basic and Clinical Immunology for the Busy Clinician symposium.
“We have a lot of new treatments and new management strategies to discuss today,” M. Elaine Husni, MD, MPH, of the Cleveland Clinic, said in her presentation.
Despite these advances, if clinicians are not attuned to the heterogeneous nature of PsA and cognizant that both psoriasis and PsA often go undetected and undiagnosed, the impact of the novel therapies will not be as profound. “There is a window of time when we can hopefully prevent or diagnose PsA earlier,” Husni said. “That has been a great area of research.”
If there was another point Husni wanted to highlight, it is that interdisciplinary care is often necessary, as patients can experience a range of skin, joint and other manifestations and risk factors. Specifically, rheumatology and dermatology, whether treating the patient synchronously or asynchronously, have key roles. “Patients appreciate this cooperation,” Husni said. “They have much more buy-in when they see us working together.”
Husni acknowledged that outside of urban areas and locations near major medical centers, care from experts across a range of fields is not always feasible. “But it is helpful to develop relationships” when possible, she said.
Forming relationships can raise red flags about the myriad risk factors for PsA, such as nail disease, diabetes, obesity, severe psoriasis, uveitis, corticosteroid use, inflammatory bowel disease (IBD), a family history of PsA, scalp and intergluteal psoriasis and HLA-B27, which is largely associated with axial PsA. “We need to make better use of our screening tools,” Husni said. “We should also have a more efficient way to refer from our colleagues in other disciplines.”
Swift referral is critical. “A delay in diagnosis of just 6 months can lead to erosions, an increased number of deformed joints and the ability to have a DMARD-free remission,” Husni said.
Once a patient has been identified, clinicians should be aware of advances in treatment recommendations and approaches. Husni suggested that an update of the 2015 GRAPPA treatment recommendations may be coming soon.
“We are looking at domain-driven treatment outcomes,” she said. “If the skin is dominant, you start with skin treatments. If joints are dominant, you start with joint treatments.”
Looking at joint ACR/National Psoriasis Foundation guidelines, Husni suggested that starting with a TNF inhibitor earlier “floats a little higher to the top” in treatment-naïve patients. “Both skin and joints do well with TNF inhibitors, but the skin does better,” she said. “We still have a long way to go in terms of joint efficacy.”
Regarding the move toward treating to target, “tight control does have better outcomes,” Husni said. “If you are not reaching your target, dose escalation is good way to reach your target.”
The discovery of the interleukin-17 pathway has been “helpful in PsA,” according to Husni. “It leads to a cascade of other functions within our immune system,” she said.
An IL-23 inhibitor may be used in “recalcitrant skin disease,” Husni added.
All of that said, while the IL-17 and IL-23 axis is “an area of great research,” experts are still unclear how the axis works in PsA, according to Husni.
All of this underscores Husni’s point that methotrexate has yielded “mixed results” in PsA. However, it may be used to prolong biologic therapy.
“Lastly, I can’t over-emphasize that this is a chronic disease,” Husni said noting that, in addition to therapeutic interventions, clinicians should encourage their patients to invest in lifestyle interventions such as a healthy diet, exercise and mindfulness.
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Husni ME. PsA. Presented at Basic and Clinical Immunology for the Busy Clinician; Feb. 5-6, 2021. (virtual meeting).
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