‘PsA doesn’t happen by itself’: Importance of multidisciplinary management
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For patients with psoriatic arthritis, collaboration between a dermatologist and rheumatologist is integral to receiving optimal care.
“PsA doesn’t happen by itself,” Saakshi Khattri, MD, an associate professor of dermatology at Icahn School of Medicine at Mount Sinai, told Healio.
In an interview, Khattri discussed the importance of multidisciplinary management of patients with PsA, the challenges involved with this approach and the importance of communication among physicians from different specialties in caring for patients.
Healio: How important is multidisciplinary management in treating patients with PsA?
Khattri: For the most part, psoriasis happens first and then patients go on to develop PsA. Therefore, multidisciplinary management with a rheumatologist and dermatologist caring collaboratively for the patient with psoriatic arthritis is very important. For example, drugs that work well for the skin are not so great for the joints and vice versa. It is important that a dermatologist and rheumatologist communicate with each other.
Additionally, patients with psoriasis or PsA can also have metabolic syndrome, insulin resistance, diabetes, hypertension, hyperlipidemia and more. Patients also need to see a primary care physician and there may be times when a dermatologist or rheumatologist has to discuss non-psoriatic issues with a patient’s primary care provider as well.
Healio: What are the challenges of pursuing a multidisciplinary approach in PsA?
Khattri: The challenge truly comes about when considering therapies for patients. As I mentioned, some medications achieve a greater response on the skin as opposed to the joints, so if the dermatologist and rheumatologist have different opinions with regard to which systemic option to use, there could be a bit of back and forth.
Also, if the patient has physicians who are at different institutions, that can be a little difficult. However, the same [electronic medical record] systems are used by most academic institutions, so if a patient allows the EMR system at one institution to communicate with the one at the other institution, that makes it easier.
Healio: How can a multidisciplinary approach help patients with PsA control pain related to the disease?
Khattri: The pain component is multifactorial. If the PsA is active, then finding the right therapy to control inflammation and hopefully then decrease, if not eliminate, pain is the goal. Sometimes, this takes trial and error with different medications or combinations of medications to find the right treatment that works for the patient. This process can take time.
That being said, if the disease is in control and the underlying active PsA is not the reason for the patient’s pain, if the patient has chronic deformed joints from older, longstanding PsA or if they have a lot of joint damage that is contributing to their pain, then sending them to pain management or to see an orthopedic surgeon to determine whether joint replacement would be helpful may be beneficial as well.
Healio: What effect does a multidisciplinary approach have on treatment adherence?
Khattri: Treatment at medical centers can go both ways with a multidisciplinary approach. Certainly, if the patient has multiple providers, treatment adherence can be reinforced because the patient will be asked which medications they are taking, whether they are actually taking them, how often they are taking them — questions of that nature. However, it could also go the other way where the patient has so many physicians that it becomes overwhelming for them. It is really patient-specific.
Healio: How can this approach lead to earlier screening, diagnosis and treatment?
Khattri: I wouldn’t say that a multidisciplinary approach can lead to earlier diagnosis of PsA because the first time a patient sees a provider may be for their skin, so they would likely see a dermatologist. The dermatologist then needs to have a high index of suspicion, or they need to ask questions that are more specific to PsA in order to refer the patient accordingly. Therefore, diagnosis of PsA comes down to the index of suspicion on the part of the primary care provider or dermatologist whom the patient sees for their psoriasis.
Healio: How important is early diagnosis to treating PsA?
Khattri: Early diagnosis is always super important. There is enough published data showing that even a 6-month delay in diagnosis can result in irreversible joint damage with poorer outcomes for patients.
There is also a trend toward dermatologists increasingly asking patients about PsA symptoms and then, accordingly, sending them to a rheumatologist for diagnosis. This can help with treatment, especially when determining which treatment is best, such as a biologic that is approved for PsA but not psoriasis.
Healio: What are the unmet needs in multidisciplinary care for PsA?
Khattri: The first unmet need is definitely early diagnosis. We should try to minimize or eliminate delayed diagnosis of PsA. From a dermatology or primary care perspective, it is also very important that we screen every patient with psoriasis for PsA, which would decrease the delay in diagnosis or at least ease the burden of delayed diagnosis because providers are actively inquiring about it.
Then, once the diagnosis is made, finding a rheumatologist who is familiar enough with PsA that they are up to date with the newest developments with regard to treatment is essential.
Also, patients need to be patient because these systemic therapies for PsA do take time to act, so they may need to give them 5 to 6 months to see if they are working.
Healio: How can multidisciplinary care for PsA be improved?
Khattri: There is certainly a trend in the academic institutions toward having a combined rheumatology/dermatology clinic, which is helpful because the rheumatologist and the dermatologist can discuss the patient. However, if an academic institution does not have a combined rheumatology/dermatology clinic, then having one physician reach out to the other, be it the dermatologist reaching out to the rheumatologist or vice versa, is important to being on the same patient when it comes to treatment.
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Healio Interview
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