Diagnosing PsA: Beyond Skin and Bones

Diagnosing PsA: Beyond Skin and Bones

Featuring Grace Wright, MD

Dr. Grace Wright delves into the complexities of diagnosing PsA, addressing diagnostic delays, and the importance of recognizing diverse symptoms and risk factors.

Watch the video to learn more.

Specialty: Rheumatalogy

Expert podcasts about emerging topics in PsA

Listen to our series of podcasts, hosted by experts in rheumatology and dermatology, addressing emerging topics in PsA.

Sex and Gender Differences in Psoriatic Arthritis

Lihi Eder, MD, PhD and Philip Mease, MD

Drs. Lihi Eder and Philip Mease discuss practice-informing sex and gender differences in how patients experience PsA, communicate symptoms, and respond to treatment.

Rheumatology

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Disclaimer

Voiceover: This content is intended for US healthcare professionals and the speakers are being compensated by BMS.


Podcast

[00:00:13 - 00:00:33] Dr. Eder Hi there. Welcome to the Sex and Gender Differences in Psoriatic Arthritis podcast, brought to you by Bristol Myers Squibb. My name is Lihi Eder. I'm an Associate Professor of Medicine and Canada Research Chair in inflammatory rheumatic diseases at Women's College Hospital and the University of Toronto in Canada.

[00:00:33 - 00:01:58] Dr. Mease And I'm Dr. Philip Mease, Director of Rheumatology Research at Providence Swedish Medical Center and Clinical Professor at the University of Washington School of Medicine in Seattle. In recent years, we've seen increasing evidence that biologic sex is associated with differences in disease characteristics, response to therapy in psoriatic arthritis and other rheumatic diseases, and other sex-specific clinical considerations. In this podcast, we're going to discuss some of the literature about sex differences in psoriatic arthritis as well as a meta-analysis led by Lihi that assessed these differences.

In a review article that was published in 2022, senior authored by Lihi Eder, we saw that male patients with psoriatic arthritis tend to have more axial involvement, more severe psoriasis and psoriatic nail lesions, whereas female patients frequently have peripheral joint involvement.

A meta-analysis analyzing sex-related differences in PsA patients participating in randomized controlled trials of various therapies was published by Dr. Eder and her group. Lihi, why don't you give us an overview of what you discovered?

[00:01:58 - 00:05:25] Dr. Eder Sure. So, as you alluded to, in this meta-analysis we analyzed 54 randomized controlled trials of advanced therapies in psoriatic arthritis involving 23,000 patients with psoriatic arthritis with a roughly equal distribution between males and females. Before I dive into the data, I wanted to first mention some of the limitations of this meta-analysis. First, we didn't have individual level data, so it means that we could not adjust for potential confounding variables like comorbidities and use of other co-medications that might have influenced the results. Secondly, most trials did not record sex disaggregated data and, therefore, we could only include nine out of 54 trials in the baseline assessment of the characteristics of patients. And, lastly, there are differences in methodology, inclusion criteria, as well as the study conduct between the different trials and that might have affected some of the results.

So, after acknowledging these, we did find significant differences in the baseline characteristics between male and female patients with psoriatic arthritis when they are enrolled into these trials. The main differences are that male patients have lower scores in pain sensitive domains and patient-reported outcomes compared to female patients. This is measured by significant lower baseline tender joint count, lower HAQ score, which measures function. They had lower clinical enthesitis and lower patient and physical global assessment. The study also found that male patients tended to have more severe psoriasis as measured by higher PASI score and they had also higher levels of C-reactive protein, which is a measure of systemic inflammation. And finally, male patients were more likely to have dactylitis compared to female patients.

Now, while these differences in PsA presentations are noted and we can think about several potential mechanisms that could explain these findings, such as differences in sex hormones, differences in the immune pathogenesis of psoriatic arthritis, but I think there is one important mechanism and this is pain and the way men and women perceive and report pain, which is not unique to psoriatic arthritis. It's been reported across different musculoskeletal conditions that female patients tend to suffer from more severe pain and generally are more likely to volunteer information about pain. And on the other hand, men tend to minimize pain and delay consultation with physicians due to pain.

It's important for clinicians to be aware of these differences in pain perception and reporting and consider them when they are assessing disease activity. But regardless of the cause of pain, whether this is inflammatory or non-inflammatory cause, it's important to manage pain appropriately, both in men and women.

[00:05:25 - 00:08:09] Dr. Mease You're absolutely right, Lihi. I can remember when we thought that most of this difference that we were observing in men and women, more pain, worse function, more depression than men, was all to be chalked up to concomitant fibromyalgia occurring in women with PsA.

Fibromyalgia is an important subject. It's a condition in which there is amplification of pain but also other items like fatigue, sleep disturbance, and so on, which is due to dysregulation in the central nervous system including neural networks in the brain. And, in people that have this condition, it makes it more difficult for us to accurately evaluate a patient with psoriatic arthritis because they have pain amplification due to the condition.

And so that, that's what we ended up chalking these differences up to. But now we're learning that there's a lot more to it than that and a lot of this, Lihi, is coming from your shop. For example, the recent study that you presented at the last congress on the proteomic differences between men and women with this rich and complicated interplay with various immunologic pathways. And then also we are learning that there are important neurohormonal differences. For example, testosterone may have an anti-pain effect. Estrogen and progesterone both have pain improving but also pain worsening aspects and it could be that women at different times of their life, pre-menopause, post-menopause, may have differences in pain regulation. Prolactin has something to do with mediation of pain.

And animal studies have been showing us that there are important differences, both in immunobiology and neurohormones between male and female animals. So I think that we're learning that it's complex and we need to take these factors into account when we're talking with our female patients and our male patients and thinking through how we evaluate them and how we make treatment choices together with the patients.

[00:08:09 - 00:10:31] Dr. Eder Thank you, Philip. This is very interesting, and I think the issue of pain is important in psoriatic arthritis and in general in rheumatology. But since pain is such a subjective measure, often it's hard to assess objectively and I think imaging is an important modality that could help us figure out the source of pain and understand the extent of disease activity in psoriatic arthritis, and here we do see some differences between males and females that are important for clinicians to know.

Female patients are less likely to develop radiographic damage in their axial and peripheral joints, so if we use only x-rays as a modality to assess damage or the impact of PsA on activity and response to treatment, we might underestimate the extent in female patients. So, considering sensitive imaging modalities such as MRI and ultrasound may be useful to assess other features like enthesitis for diagnosis or monitoring of disease activity, and I think this is important for clinicians, both for diagnostic purposes and also for monitoring of disease activity in psoriatic arthritis.

I would like to return to the meta-analysis that we discussed before. And in this meta-analysis we also assessed the differences in response to therapy between male and female patients. We considered a total of 18 trials, and we evaluated efficacy endpoints by sex and specifically we looked at ACR20/ACR50 response as well as achievement of a minimal disease activity state. And when considering all medications, we found that male patients are more likely to achieve these efficacy endpoints, so ACR response showing an odds ratio between 1.5 and 1.8, favoring male patients. And when considering a minimal disease activity state, male patients had over twofold higher chances of achieving a minimal disease activity state. What are your thoughts, Philip, on these findings?

[00:10:31 - 00:12:27] Dr. Mease So to unravel this, can we trust these ACR numbers in females that are showing higher rates of disease activity at baseline and then less response over time? I think that it really is going to be important to take a look at ultrasound to see if there's genuine inflammatory activity. Women in my practice, when they come into the office, they express more pain and fatigue than men do. They have more work disability, worse physical function, worse quality of life, and we're trying to capture all this in metrics like minimal disease activity and the women they're not getting to the state of MDA that men do.

And what this then leads to is more cycling from one medication to another. So they're not as persistent on any given drug that you give them and then also are wanting to move on and try a different medication. And so, we're running out of medications to try a little bit quicker in women than men.

And I think it's important to be reassuring, to say, well, understand completely that you're not feeling well, but let's look at other ways rather than cycling to think about how to deal with this. And I think it opens up some really neat conversations about their psycho-emotional health, what areas in their life are they frustrated with, are there things that we can be reassuring about and sort of partners with them to get them through having this illness and get to a better place in their lives?

[00:12:27 - 00:13:39] Dr. Eder Another important consideration for female patients is how does pregnancy affect psoriatic arthritis. And we know from previous studies, mostly in PsA but also in rheumatoid arthritis, that disease activity tends to improve during pregnancy but may flare after during the postpartum period. So this is an important conversation that we need to have as clinicians with our female patients that are considering pregnancy to inform them what is the likelihood of them experiencing symptoms of psoriatic arthritis during pregnancy and the risk of flaring afterwards.

The other important topic here is the discussion of pregnancy plan and conception with our female patients because this will have implications on what type of medications we can offer them. So it's important to share this with our female patients.

Philip, can you share your thoughts on the multidisciplinary management of women across the lifespan? Any important considerations?

[00:13:39 - 00:15:02] Dr. Mease Well, one for sure is that with my patients that are in their mid to late 40s and beyond, there is the issue of getting into perimenopause and then menopause itself. And in some women, they seem to go through this period quite normally and reasonably, but others seem to have quite significant symptoms associated with the menopausal state, poor sleep, just feeling crummy in general. And I have had a number of patients where I'm going, oh, is this their psoriatic arthritis that's acting up and is not being adequately controlled that's leading to this achiness and fatigue and so forth or is it the fact that they don't have any estrogen anymore? And working with gynecologists who then are better able to assess, counsel, can really make a difference. And so, like other phases of life where we are working with other team players like physical therapists and cardiologists, I think that it's important to work with primary care physicians and/or gynecologists to counsel through this stage of life.

[00:15:02 - 00:16:15] Dr. Eder We are getting close to the end of this podcast, and I would like to summarize key points discussed today. We discussed that there are significant differences in disease presentation, in treatment response that are important for clinicians to be aware of when it comes to assessing their male and female patients with psoriatic arthritis. There are still significant gaps in knowledge regarding what are the underlying mechanisms behind these differences, so there is ongoing research that is trying to illuminate some of these mechanisms. And finally, we've tried to highlight here some practical aspects and key messages that clinicians should be aware of regarding the differences and how to apply them in practice when it comes to the diagnosis, monitoring of disease activity, and selection of treatment or of treatment strategies.

And that wraps up our discussion on Sex and Gender Differences in Psoriatic arthritis. Huge thanks to you, Philip, for that thoughtful conversation and to our audience for spending time with us today.

[00:16:15 - 00:16:44] Dr. Mease Thanks so much, Lihi. This was wonderful to share this conversation with you. I've learned a lot from working with you on these studies, like the meta-analysis and the studies that are coming out of your shop that are really shedding light on this subject that hasn't really been well-covered before. I think you're quite pioneering in this area and I really appreciate you all listening to learn more about this subject.

[00:16:44 - 00:16:45] Dr. Eder Thank you.

IMM-US-2500089 06/25

Rheum-Derm Co-Management of Patients with Psoriatic Disease

Ruth Ann Vleugels, MD, MPH, MBA and Gordon Lam, MD

Drs. Ruth Ann Vleugels and Gordon Lam discuss ways to facilitate partnership between rheumatologists and dermatologists to enhance PsA care.

Rheumatology

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Disclaimer

Voiceover: This content is intended for US healthcare professionals and the speakers are being compensated by BMS.


Podcast

[00:00:12 - 00:00:37] Dr. Vleugels Welcome to the Rheum-Derm Co-Management of The Patient Podcast, brought to you by Bristol Myers Squibb. My name is Ruth Ann Vleugels, I'm a professor and distinguished chair of dermatology at Brigham and Women's Hospital and Harvard Medical School, where I lead the autoimmune skin disease program in the connective tissue disease clinics. And I'm extremely passionate about this area of derm-rheum. I'm the immediate past president of the Rheumatologic Dermatology Society. I'm excited to be here today with Doctor Gordon Lam.

[00:00:37 - 00:01:50] Dr. Lam Thank you. And Ruth Ann let me just start by saying how excited I am to be here and honored to be here with you. I'm Gordon Lam, I'm the medical director of clinical research with the Arthritis & Osteoporosis Consultants of the Carolinas, and a clinical affiliate with Atrium Health, Wake Forest Baptist, part of the Wake Forest University School of Medicine in Charlotte, North Carolina.

Ruth Ann, in recent years, we've seen increasing evidence that rheumatology – dermatology co-management is associated with improved care and decreased time to diagnosis in psoriatic disease. In this podcast, we'll discuss key aspects of the rheum-derm co-management and its implications in clinical practice. Now, as you know, many patients with psoriatic arthritis or PsA are often seen by a dermatologist first because of their skin disease. And as such as a dermatologist, you play a really crucial role in identifying potential psoriatic arthritis by screening for joint pain or other symptoms and then referring to a rheumatologist if necessary. So, tell me, what does that look like to you? How do you do that? What signs are you looking for? Do you use any tools to help assist? And then when do you refer your patient to a rheumatologist?

[00:01:50 - 00:04:42] Dr. Vleugels Gordon, those are all fantastic questions. And I think something that we really want to remind our listeners is that more than 80% of patients who eventually develop psoriatic arthritis develop it after their diagnosis of psoriasis. So, it's super important that in the derm clinic we're on the lookout for these patients. And we really are thinking about screening them early to give them a better chance of less disability from their arthritis.

I think one of the really important studies that I'll often mention is that we know that when we look at well over 1000 psoriasis patients and we think about those that later develop involvement of their joints, we know that there are high risk features that we can actually see on exam in the clinic and the things that I would want all my derm colleagues to realize, and of course, my rheumatology colleagues, as well, is that the scalp involvement, nail involvement, and also sort of intergluteal perianal involvement all have an increased risk of arthritis. And in addition, people with more extensive disease, in particular those with over three sites of involvement, also have an increased risk of arthritis. These are things we're going to be looking for in the clinic. And although we want to screen all patients for involvement of their joints, these are patients in which you're going to be particularly concerned. In order to address your second question, there's screening tools we can use. And these are particularly used in dermatology clinics or primary care clinics.

I'm going to first walk you through the two screening tools that are most often used. The first is the Psoriasis Epidemiology Screening tool, often referred to as PEST. And this is just five simple questions, and if the patient has three out of five positives, then they are likely to have a diagnosis of psoriatic arthritis. And the simple way to think about this is one is actually asking the patient if they have been diagnosed with arthritis, and then we ask them if they've had a swollen digit. Thinking about our dactylitis patients. We ask them about heel pain, if they have had nail pits or holes, and then if they've had joint swelling. So, they are very, very simple questions.

Another one we often use is our Psoriatic Arthritis Screening and Evaluation Questionnaire. And really when we do this, we're trying to think about who we need to get into rheumatology quickly. This was actually developed at my hospital, Brigham and Women's Hospital, by many of our colleagues and our Psoriasis Joint Rheumatology Dermatology clinic. If you don't have time to do these screening tools, I just want you to think about the questions I just mentioned and what you may want to ask your patient in clinic. So common ones would be do you have any morning stiffness? Do you have any back pain? These are really two crucial questions. I think if you can add in the heel pain and look at their nails, ask about swollen digits or inflamed joints. This really gets you to where you need to be and really, you're going to know which of those patients you want to get into your rheumatology colleagues right away. Gordon how do you think we're doing with that?

[00:04:42 - 00:06:30] Dr. Lam You bring up really important points and some of the points that I think are very important from a rheumatologist's perspective. So as part of the rheum boards, one of the questions is the percentage of patients who first present with psoriasis and then psoriatic arthritis. And as you mentioned, the majority of patients will develop the arthritic component after the psoriasis component. But the question is which of those patients are at higher risk to develop the arthritic component? So, you mentioned some really good pearls for rheumatology colleagues. For example, the scalp involvement, the nail dystrophy, the intergluteal/perianal lesions and then the three or more affected sites. That's really good for us to know as well. So, we have a lot of learning points from you and dermatology colleagues.

And I think the screening tools that you folks use are fantastic. But I'll tell you, to make it easy for our community dermatologists, we simply tell them, if you have a patient who has psoriasis and if they're complaining of any joint pain, just feel free to refer them over. And the reason is because not only can we rule in psoriatic arthritis, but we can also rule out other conditions. So, for example, let's say they have psoriasis and just osteoarthritis or psoriasis and fibromyalgia. And it's not truly inflammatory psoriatic arthritis. I think that's still a very valid reason for referral. One of my really good friends and colleagues, Phil Mease from the Seattle area did a trial back in 2013, I think he called it The PREPARE Trial and all he did was simply he and his colleagues follow dermatologists in their clinics, and every time they saw a patient with psoriasis, they would then pull them aside and see if they had psoriatic arthritis. And about 30% of patients who had psoriasis had psoriatic arthritis. So, I think that it's very valid and helpful to feel free to just call your local friendly rheumatologist and to have them collaborate and care.

[00:06:30 - 00:07:32] Dr. Vleugels Gordon, I love that. That reminded me of an important point, which is that from our studies, we know that a third of our psoriasis patients actually have a diagnostic delay of over five years to get their arthritis diagnosis, which is really a shame, right? Because we know that there's some guidelines that suggest that the maximum wait time should be six weeks. And so, we're really having this gap in our ability to diagnose patients quickly. And we really want to engage our rheumatology colleagues early to make sure we're not missing this diagnosis.

So, Gordon, we are both well aware that when we can diagnose these patients with arthritis early, that we can prevent or inhibit joint damage. We know that when we look at patients before and after implementation of a specialized psoriasis and psoriatic arthritis center, we know that we have a decreased delay in diagnosis in these patients when we're working collaboratively. I'm sure our audience would love to hear about your experience as a rheumatologist, communicating and collaborating with dermatologists for more integrated treatment approaches.

[00:07:32 - 00:10:06] Dr. Lam Yeah, absolutely. And in fact, I feel very invested in this. When I was at Hopkins in the mid to late 2000s, we created some of the first interdisciplinary clinics across the various rheumatic diseases whether it was myositis, lupus, Sjögren's syndrome, where we integrated rheumatologists, dermatologists, neurologists, pulmonologists, etc. and it not only led to better outcomes, but it was actually just more fun, I'll be honest with you.

So you mentioned that rheumatology-dermatology collaborations are associated with increased numbers of patients who are diagnosed with psoriatic arthritis, and diagnosed appropriately and diagnosed earlier. And the key to any disease state is early diagnosis, implementation of appropriate therapy because that can then lead to improved outcomes. But I also state from sort of a broader perspective, you know, shared decision making is always important.

Shared decision making has been a key topic in all of medicine and for a very valid reason. Shared decision making, as you know, is the collaborative process between the patient and his or her provider. Where decisions are made first and foremost based on evidence, but also taking into account other factors: patients' preferences, past experiences, everything from socioeconomic status, religious beliefs, etc. Only by doing that can we come to the best therapy for the patient.

And I was always trained with the mantra, we should always try to find the right medication for the right patient at the right time. When it comes to rheumatology-dermatology collaboration and across the interdisciplinary clinics, I just have this simple thought that two brains are better than one. And when you include the patient, then it's three brains are better than one.

Now there are different models and, Ruth Ann with your academic position I'd really love to hear your thoughts about this, but there are different models as to how to do rheumatology-dermatology clinics. We know that some healthcare centers have dedicated PsA clinics or specialized clinics, where rheumatologists and dermatologists work side by side to manage patients.

There are specific conferences, supported by associations like GRAPPA. And I have to say, GRAPPA is one of my favorite organizations, because not only does it bring together rheumatologists and dermatologists, but it also includes patients and then, of course, the study that you mentioned, which shows that having these combined clinics leads to reduced waiting times to referral to rheumatologists, time to diagnosis, improved outcomes. But the question is, how do we do this? I'd be interested to see how you do it there at Harvard. And then, some of the experiences that I've had outside of it and then other models that I've heard from colleagues in the community.

[00:10:06 - 00:11:08] Dr. Vleugels Yeah. So, we're very spoiled at Brigham and Harvard because we do have joint clinics, and we also have a separate psoriasis and psoriatic arthritis clinics, where we have dermatologists seeing those patients alone. But in our joint clinics, I think the phenomenal addition is we really get dual training, dual teaching between our dermatologists and our rheumatologist. So, I always love it.

Often a patient will come in, referred from a rheumatologist, and maybe their joints are doing well, but they still have substantial scalp disease. And maybe the scalp isn't a typical part of the exam for our traditional rheumatologist. Or I can teach my rheumatology colleagues, what are the nuances of the nail exam? I think that's really helpful. And then on the flip side, I learned from my rheumatology colleagues every day. So, for example, one of my early pearls I learned was, you know, when you have arthritis at the base of the thumb, that's almost always osteoarthritis. Just pearls that really impact our ability to see patients over time, that we can pass on to our trainees and then regardless of their practice location, can improve the care of patients with psoriasis and psoriatic arthritis moving forward.

[00:11:08 - 00:11:37] Dr. Lam But what does that look like to you? So, I've heard of models where the dermatologist would see the patient first, then the rheumatologist see the patient next. And then they'll both come in and discuss the patient together in front of the patient. I've heard of other models where the patient may have a rheumatology appointment in their clinic, then very shortly thereafter, like that same day or the next day, they'll have an appointment with dermatologists in his or her office. And then the dermatologist rheumatologist will then meet afterward or communicate independently. So how does it work there at Brigham?

[00:11:37 - 00:12:37] Dr. Vleugels So, Gordon, great question. And we are sort of an embarrassment of riches because we actually have 14 derm-rheum clinics a week in our department. And so, we actually have both models. We have models where the person sees rheum and derm on the same day, but not in the same exact clinic location. And they make maybe a 15-minute walk between the two, and then we communicate with each other after, which I think is less ideal but still works well. As you highlighted, as long as we're in close communication, our patients still have better outcomes.

And then we have other sessions where we actually have a rheum trainee and a derm trainee go in first, and then they actually come out and they present to both the dermatology and the rheumatology attending. We all go in together, do teaching, come up with the best treatment approach for the patient, and it's all done simultaneously. We have both of those models. And I do think there's advantages and disadvantages to both. But as you highlighted earlier in the podcast, the most important point is just regular, frequent communication between that dermatologist and rheumatologist to get the best outcome for the patients.

[00:12:37 - 00:15:12] Dr. Lam I absolutely agree the consistent communication, as you mentioned, is beneficial to monitor treatment effectiveness, to adjust treatment strategies as needed, to ensure coordinated care, and to lead to improve outcomes. But I think the reason why I'm asking is because from the perspective of our colleagues in the community, they're probably wondering, well, I'm not an academic medical center, so how do we make this work?

And in talking with some of my colleagues across the country, the interest and the demand and the excitement for interdisciplinary clinics is very great. Everyone will agree that that's a great idea. But the question is, how do we make this work in the real world?

When I was in the hospital, it was easy because we had a set-up very similar to yours. When they moved our office in a building that was outside of the hospital, we arranged that so that my office was right next door to dermatologist office, so patients could literally shuttle back and forth, but I realized that that may not be realistic or practical. What people have mentioned is, they may coordinate a half day a week where the dermatologist comes to the rheumatologist office and they see patients scheduled specifically for the question of psoriatic arthritis, or vice versa. The rheumatologist goes to the dermatology office for half a day, and then they could do it sort of remotely. We learn how to do virtual medicine very proficiently and fluently, where the patient can see the dermatologist, rheumatologist, asynchronously and then the two can then meet virtually or by phone, or discussion. Now the communication can take place in many different formats. It could be something as simple as sharing notes. It could be something as simple as portal messages. But what I really recommend, I'm kind of old school, just to show my age, but I think nothing can beat a phone call.Just pick up the phone, and you can even schedule a specific time of the week. And then just to talk about patients. And that way if you're doing it asynchronously, you can go through the chart of patients. Each can take notes and then you can still have the same benefit.

However, I will mention the benefits of being there in person. You can see different clinical features. You can communicate them. You can point them out. More importantly, we can learn from each other. I can't tell you how much I've learned from my dermatology colleagues, but you can also get real time input from the patient. But at the end of the day, it just makes it that much more gratifying and satisfying for these patients.

So, Ruth Ann, I think we both agree that it's very exciting for the future and potential of improved communication and co-management of these psoriatic arthritis patients by dermatologists and rheumatologists. But give me some of your thoughts about the impact it will have on some of your patients' quality of life.

[00:15:12 - 00:15:52] Dr. Vleugels Yeah, I think that's a fantastic question because that's really what we're striving for, right? We want our patients to leave the office and feel heard, and that we have solved what they came to us to give them help with. So, I think with comprehensive evaluations from both dermatology and rheumatology, we know that we not only have earlier detection of psoriatic arthritis, but we also have a coordinated approach to improve the quality of life of our patients, to ensure we're helping them with both their skin and joint disease.

And I'd love to hear your thoughts about that as well. But clearly, I'm a huge advocate for thinking about patients from a joint dermatology and rheumatology perspective. I really do think it impacts our patients' quality of life for the better.

[00:15:52 - 00:16:56] Dr. Lam Yeah, I agree, and psoriatic arthritis is one of the more complex and heterogeneous diseases in rheumatology. And the manifestations can extend well beyond the joints and the skin. I'll be honest with you, I'm guilty of sometimes just being so hyper focused on the joint that I miss that psoriatic lesion that would be staring a dermatologist like yourself in the face.

But there are other manifestations and comorbidities that may be at play as well. And it always helps to have an extra set of eyes, an extra set of ears, an extra set of hands to evaluate the patient so that we don't miss them. And by better addressing the skin and joint issues and having a more coordinated approach, we can then better address the patient.

And I think by having better disease control, adherence is also really important. We know that patients can only get better if they follow a plan and take a medication, but I also think going back to shared decision making, it helps just to have, someone else who can provide further evidence from which to base therapy and then to have further input as well.

Ruth Ann, any other last thoughts before we close?

[00:16:56 - 00:17:03] Dr. Vleugels I really appreciated all of those recent comments, and I really appreciate this podcast working with you, Gordon. I really enjoyed it a lot.

[00:17:03 - 00:17:59] Dr. Lam Oh, me too. I can't tell you what an honor and pleasure it is to work with you as well. And I also want to take a quick second to thank all of our listeners for taking some time out of your busy schedules to listen as well. I really hope that you found this discussion to be useful, engaging, thought provoking, and informative.

And I really want to emphasize that having specialized dermatologic and rheumatologic patient management may help to more accurately diagnose patients with psoriatic arthritis, to do so in a more timely manner. The hope is that this will then lead to earlier treatments for the patients and better outcomes, and by having a more holistic understanding of patients' individual needs and disease presentation when treatment selections are being made, this may ultimately lead to a better outcome for our patients.

And I always think that in general in life, if you're going to do something, you might as well have fun doing it. So, with that, thank you so much for your time and your attention.

IMM-US-2500051 06/25

Navigating Treatment Challenges in Psoriatic Arthritis

Lourdes Perez-Chada, MD, MMSc

Dr. Lourdes Perez-Chada talks about challenges clinicians and patients may face in treating PsA, and potential strategies.

Rheumatology

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Disclaimer

Voiceover: This content is intended for US healthcare professionals and the speaker is being compensated by BMS.


Introduction of Podcast and Speaker

[00:00:12 - 00:00:45] Dr. Perez-Chada Welcome to the Navigating Treatment Challenges in Psoriatic Arthritis podcast, brought to you by Bristol Myers Squibb. I am Lourdes Perez-Chada, board member of the International Dermatology Outcome Measures, member of the Scientific advisory committee of the National Psoriasis Foundation, and member of the steering committee of the Group for Research and Assessment for Psoriasis and Psoriatic Arthritis. Today, we will be tackling an important and often frustrating topic: what happens when patients don't respond to treatment?

[00:00:46 - 00:01:08] Dr. Perez-Chada Psoriatic arthritis, or PsA, is a chronic inflammatory disease that can affect the skin, joint, and entheses, where tendons and ligaments insert in the bone, as well as other domains, which was discussed in one of our videos. For many patients, finding the right treatment is a journey and one that doesn't always follow a straight path.

[00:01:08 - 00:01:34] Dr. Perez-Chada Although many treatment options are now available for PsA, there is still an unmet need. With one retrospective analysis of a longitudinal cohort suggesting that as many as 70 to 80% of patients with PsA do not reach a target of sustained remission or very low disease activity. So, what do we do when the treatments we rely on don't deliver the relief we expect?

[00:01:34 - 00:01:46] Dr. Perez-Chada Today, we will explore why treatments may fail and what steps healthcare providers might consider to adjust and optimize patient care. Let's break it down.

Segment 1: Understanding Inadequate Treatment Response in Psoriatic Arthritis

[00:01:46 - 00:01:59] Dr. Perez-Chada In clinical settings, inadequate response refers to a situation where a treatment does not achieve sufficient disease control based on patient's symptoms, physician assessment, and treatment goals.

[00:01:59 - 00:02:39] Dr. Perez-Chada Inadequate response is typically classified as primary or secondary. We refer to primary inadequate response when patients lack initial clinical response to a therapy within an appropriate timeframe. For example, patients may continue to experience joint pain, stiffness, and fatigue despite treatment. And we refer to secondary inadequate response when the patient initially improves but loses response after months or years of therapy. Such loss of response may be due to altered drug metabolism or clearance, or the development of anti-drug antibodies, as in the case of biologics.

[00:02:39 - 00:02:53] Dr. Perez-Chada Patients may also present intolerance to therapy where side effects outweigh the benefits leading to discontinuation. When any of these occur, it's important to reevaluate and adjust the treatment approach.

[00:02:53 - 00:03:21] Dr. Perez-Chada Understanding inadequate response revolves around a comprehensive approach that may include patient-reported outcomes, clinical assessments, and imaging. It is not just about numbers. It is about how the patient feels and functions in their daily life. A mismatch between physician and patient perceptions of the impact or the severity of PsA and satisfaction with the treatment has been reported in various studies.

[00:03:22 - 00:03:43] Dr. Perez-Chada In a retrospective study of 305 paired patients with PsA and rheumatologists in the United States, about 24% of the pairs were found to have a mismatch in treatment satisfaction, and these patients reported greater disease burden and work productivity impairment.

[00:03:43 - 00:04:12] Dr. Perez-Chada Another study that was a quantitative survey that included 256 patients with PsA found that around 34% of 238 respondents with PsA have not had the opportunity to discuss or set treatment goals with their physician. And around 16% of 238 respondents with PsA were not very satisfied or not at all satisfied with their physician.

[00:04:12 - 00:04:33] Dr. Perez-Chada Furthermore, around 28% of 228 respondents with PsA were not very satisfied or not at all satisfied with their current treatment, and more than half indicated that there was no difference or worsening of their disease burden with treatment.

[00:04:33 - 00:04:45] Dr. Perez-Chada It has been proposed that shared decision-making and a deeper understanding of treatment choice, goals, and expectations of patients may help improve patient satisfaction and management.

Segment 2: Why are some patients thought to be more challenging to treat than others?

[00:04:45 - 00:05:14] Dr. Perez-Chada So why are some patients thought to be more challenging to treat than others? Well, PsA is a complex disease such that what works for one patient may not work for another. Here are a few common reasons for variability in response to treatment. Disease heterogeneity: PsA affects multiple clinical domains, including peripheral arthritis, axial disease, enthesitis, dactylitis, and skin and nail psoriasis.

[00:05:14 - 00:05:49] Dr. Perez-Chada PsA can also present with extra-musculoskeletal manifestations such as IBD or uveitis. A treatment may address one domain but fall short in others. Another factor is the variability in mechanistic targets: targeting some pathways might work for some aspects of PsA but not others. Therefore, GRAPPA recommendations for PsA are based on the domains being targeted such that the treatment recommendations for peripheral arthritis may be different from recommendations for axial disease or for extra-musculoskeletal manifestations.

[00:05:49 - 00:06:24] Dr. Perez-Chada Other factors that make treatment more challenging for certain patients include environmental, microbiome, and lifestyle factors. For example, alcohol consumption, tobacco use, and intestinal dysbiosis can also drive psoriatic disease and may also need to be addressed. There is also variability in drug absorption and metabolism: genetic variability in drug metabolizing enzymes, liver and kidney function, and drug interactions also influence how PsA medications work in different patients.

[00:06:24 - 00:06:36] Dr. Perez-Chada Then there is also delayed diagnosis. In some cases, by the time the treatment starts, irreversible joint damage may have already occurred, making symptom management more difficult.

[00:06:36 - 00:06:56] Dr. Perez-Chada We should also consider factors such as patient adherence, underlying comorbidities, socioeconomic factors, and sex. Regarding patient adherence, it's important to acknowledge that medications can be challenging to take regularly, whether due to cost, side effects or lifestyle factors.

[00:06:56 - 00:07:29] Dr. Perez-Chada In terms of underlying comorbidities, conditions such as obesity, diabetes, or cardiovascular disease can complicate psoriatic arthritis treatment effectiveness. Other medical conditions like fibromyalgia, can complicate disease management. When thinking about socioeconomic factors, financial considerations, either for patients or for health care systems, can further limit treatment options, and a balance between costs and expected benefits is necessary for each patient.

[00:07:29 - 00:08:01] Dr. Perez-Chada And finally, when thinking about sex differences, female sex is also thought to affect PsA manifestations and prognosis. Women may have lower response to treatment, higher disease activity, and lower treatment persistence rates than men. Those are all key factors that together underscore why individualized treatment strategies and regular follow-ups are so important. Additionally, patient expectations and education play a big role.

[00:08:01 - 00:08:14 ] Dr. Perez-Chada If patients do not fully understand their treatment plan, they might discontinue medication prematurely or not report issues promptly, highlighting the need for clear communication and shared decision-making.

Segment 3: Things to Consider When There is Inadequate Response to Treatment

[00:08:14 - 00:08:40] Dr. Perez-Chada So, if your patient is facing inadequate response to therapy, what might you consider? Here are some potential strategies. First you can reassess the diagnosis. Could there be another condition mimicking PsA? Sometimes overlapping autoimmune diseases or mechanical issues can be at play. You could also check medication adherence. Is the patient taking the medication correctly?

[00:08:40 - 00:09:17] Dr. Perez-Chada Another strategy is to evaluate the need for combination therapy. Once treatment failure is determined, certain therapies may be combined to enhance disease control, especially in patients with refractory PsA or multiple disease domains. Combination strategies may help restore treatment efficacy. Medications may also be combined to target different inflammatory pathways involved in the pathogenesis of PsA for broader immune modulation, though these approaches require careful monitoring for safety and efficacy.

[00:09:17 - 00:09:56] Dr. Perez-Chada You can also consider switching therapies. PsA treatments span multiple drug classes including antimetabolites, immunosuppressants, TNF inhibitors, IL-17 and IL-12/23 inhibitors, CTLA-4 inhibitors, JAK inhibitors, PDE4 inhibitors, biologic and conventional synthetic DMARDs. If a patient does not respond adequately or loses this response over time, it might be worth switching medications, whether in the same class or to a different mechanism, to see if the patient can improve.

[00:09:56 - 00:10:26] Dr. Perez-Chada And in clinical practice it's essential to have an open dialog with patients. Understanding their concerns, expectations and lifestyle can help tailor an approach that works better for them. For example, encouraging weight management, exercise, smoking cessation and mental health support can enhance treatment effectiveness. Similarly, engaging patients in shared decision-making ensures they feel heard and empowered in their treatment journey.

Segment 4: The Emotional Impact of Inadequate Response

[00:10:26 - 00:10:37] Dr. Perez-Chada Beyond clinical outcomes, patient-reported outcomes, including measures of health-related quality of life, provide actionable insights into how PsA truly affects patients' lives.

[00:10:37 - 00:11:02] Dr. Perez-Chada Let's not forget the emotional toll treatment failure can take. Patients often feel discouraged, frustrated, or even hopeless when their treatment isn't working. This is where healthcare providers play a key role, not just in offering new options, but in providing reassurance and support. Living with PsA can adversely affect the emotional well-being and relationships of patients.

[00:11:02 - 00:11:36] Dr. Perez-Chada In a study conducted by Coates et al, 69% of patients with PsA reported that the disease had a significant impact on their emotional and mental well-being, 56% reported effects on romantic relationships and intimacy and 44% indicated an impact on relationships with family and friends. Encouraging patients to advocate for themselves, seek second opinions, if necessary, and stay informed about treatment options can make an important difference.

[00:11:36 - 00:11:49] Dr. Perez-Chada Active listening and open communication can build trust and empower patients to take a more active role in the management of their disease. Providing mental health resources and support groups can also be valuable.

Takeaways and Closing

[00:11:49 - 00:12:20] Dr. Perez-Chada The good news? PsA treatment options are evolving rapidly. Ongoing research into new therapies offers hope for increasing options for patients to find the optimal treatment for them. Precision medicine and biomarker driven approaches are currently being studied and may lead to more targeted therapies. Managing PsA requires a collaborative, proactive approach—one that adapts to the patient's unique needs and changing disease state.

[00:12:20 - 00:12:41] Dr. Perez-Chada Treatment challenges in psoriatic arthritis is multifaceted and requires a thorough reevaluation of the patient's condition and therapy. Individualized treatment strategies, combined with patient education and support are important for successful outcomes. Thank you for tuning in to navigating treatment challenges in Psoriatic Arthritis.

[00:12:41 - 00:12:49] Dr. Perez-Chada I hope you found this discussion insightful. Until next time, stay informed and proactive in managing psoriatic arthritis.

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