Transcript
Announcer:
You’re listening to On the Frontlines of Psoriatic Arthritis on ReachMD. Your host today is Dr. Mary Leuchars.
Dr. Leuchars:
This is On the Frontlines of Psoriatic Arthritis on ReachMD, and I'm Dr. Mary Leuchars. Today, I'm joined by Dr. Bret Sohn to discuss the challenges of diagnosing and treating psoriatic arthritis and strategies for overcoming them. Dr. Sohn is a board-certified rheumatologist practicing with Stanford Health Medical Group in Connecticut. Dr. Sohn, welcome to the program.
Dr. Sohn:
Thank you so much for having me.
Dr. Leuchars:
So jumping right in, Dr. Sohn, psoriatic arthritis is often described as under-recognized. In your experience, what makes it so easy to miss or misdiagnose in practice?
Dr. Sohn:
That's a great question. Psoriatic arthritis has many different manifestations. It's not always strictly a joint issue, but it often starts as a soft tissue issue in the tendons. And when that happens, it may manifest as sausage digits or pain around soft tissues, on the elbows, or even in the back. And oftentimes, this may mimic other types of problems, including osteoarthritis or fibromyalgia. Sometimes, even gout can resemble this. And in some cases, although we typically expect patients with psoriatic arthritis to have skin psoriasis, sometimes, rarely, about 10 to 15 percent of the time, patients may present with the joint manifestations first, even before the skin manifestations. And very rarely do we find that patients have the manifestations of psoriatic arthritis without any skin psoriasis. Again, it takes a good amount of detective work to be on alert for signs or symptoms that could make sense for psoriatic arthritis.
Another challenge is there are no biomarkers. There's no blood test to tell a patient if they actually have psoriatic arthritis. It is very much a clinical diagnosis. And so, again, it relies very much on that individual provider, their experience, exam findings, and the patient’s overall history to tease out if a patient could have psoriatic arthritis.
Dr. Leuchars:
And as a brief follow-up to that, what are the consequences for the patient when diagnosis is delayed?
Dr. Sohn:
It's been shown that even a delay by as little as six months can actually lead to early damage. And having that damage can actually impact that patient's day-to-day life, overall ability to carry out activities of daily living, and overall pain and fatigue that they might experience. Once that damage occurs, it's very hard, obviously, to repair that.
Dr. Leuchars:
Many patients with psoriatic arthritis are first seen by a dermatologist or primary care clinician rather than a rheumatologist like yourself. Knowing that, what are the key signs or symptoms that should prompt these clinicians to think about joint involvement and consider referral?
Dr. Sohn:
So I think that, in any patient who has skin psoriasis, you need to be on the lookout for joint manifestations. And so it's so important to make sure that you're asking those patients about swollen joints, prolonged stiffness in the morning that occurs for more than 30 minutes, and unexplained back pain. And make sure that you have a good connection with a rheumatologist.
Look for signs and symptoms like sausage digits, which are also very characteristic of psoriatic arthritis. When you see a patient with sausage digits, again, that's something that should tip you off that there could be psoriatic arthritis there. In addition, for a dermatologist, you need to understand that there are some high-risk types of psoriasis that have a higher predilection for developing psoriatic arthritis in the future. That may include scalp psoriasis, nail disease, inverse psoriasis, or just an overall heavy extent of psoriasis as far as body surface area. When we see patients with that, especially in the dermatology clinic, we really should be on high alert that the patient may develop psoriatic arthritis at some point.
Dr. Leuchars:
And outside of knowing those signs and symptoms, what can clinicians across all specialties involved do to make recognition and diagnosis smoother and quicker?
Dr. Sohn:
So there are some questionnaires that exist, such as what's called the PEST questionnaire. It's the Psoriasis Epidemiology Survey Test. And that, basically, helps to capture patients who might have psoriatic arthritis: patients with psoriasis who possibly experience joint pain or pain at an Achilles insertion or in soft tissues, which could resemble enthesitis. With those sorts of questionnaires, you can ensure that a patient is answering questions related to their joints.
In addition, it would be very good to have a good network of rheumatologists that you can call if you see somebody that could have psoriatic arthritis. This’ll be somebody that you can call immediately and get the patient in for an evaluation.
Dr. Leuchars:
For those just tuning in, you're listening to On the Frontlines of Psoriatic Arthritis on ReachMD. I'm Dr. Mary Leuchars, and I'm speaking with Dr. Bret Sohn about ways to improve diagnosis and management.
So, Dr. Sohn, let's shift gears now and talk about treatment. Once psoriatic arthritis is confirmed, what are the biggest hurdles you run into when choosing and starting the first therapy, and how do you work through them?
Dr. Sohn:
So, first of all, we are fortunate that, in this day and age, there is an emerging treatment landscape for patients with psoriasis and psoriatic arthritis, and that's a great thing, overall, for everybody—the providers and the patients.
There are certain things that you need to consider when you're deciding on a treatment protocol for patients. So, first of all, we need to think about potential safety. Some medications may have warnings about cardiovascular events, thrombosis, stroke, or malignancy. Some patients prefer oral therapies, and some prefer injectable therapies. Some patients also prefer IV therapies. In addition, there are insurance hurdles, in that some insurance plans, such as government insurance plans, may limit the options that a patient may have there.
We also need to take into account the manifestations that a patient has. Do they have more prominent dactylitis with those sausage digits? Do they have more axial disease? Is their psoriasis the most prominent issue? Those sorts of things do impact the types of treatments we may consider.
Dr. Leuchars:
We know that comorbidities like obesity, cardiovascular disease, and depression are common in psoriatic arthritis. How do these factor into your treatment decisions, and how do you address them in a busy practice?
Dr. Sohn:
So we know that many of our patients have concomitant comorbidities, and we know that psoriatic arthritis and psoriasis on its own have a higher incidence of concomitant obesity, heart disease, and depression. And so we need to take those factors into account when we're choosing our treatments.
We need to make sure that, at each visit, we coordinate with the primary care doctors. We want to make sure that we keep all of their care team on board. We want to make sure that if there are comorbidities that aren't being addressed at the time we meet them, we raise that with their primary care doctor or even other specialists, such as their endocrinologist or cardiologist, to make sure all these conditions are optimized together.
Dr. Leuchars:
Even after all of that, many patients don't get to remission or low disease activity right away. What are the most common reasons you see for that, and what strategies do you use to help patients reach their treatment target?
Dr. Sohn:
The biggest thing that I actually say when a patient with psoriatic arthritis is not feeling better or they feel like there are continued symptoms is, number one, let’s go back to the diagnosis. Are we sure all their symptoms can be attributed to psoriatic arthritis? Many of these patients have other reasons for pain, including osteoarthritis, degenerative arthritis, or chronic pain for other reasons. Many of our patients will also have concomitant fibromyalgia symptoms or sleep apnea, which can lead to chronic pain as well. That is not, unfortunately, going to respond to our immunotherapies.
Always making sure we set an expectation for each of these therapies with our patients is very important. We also need to understand that some patients can't tolerate side effects and that we need to take into account their schedule. Sometimes, patients can't adhere to a certain biologic therapy or an infusion schedule, and maybe they would be better off with an oral therapy, or vice versa.
So, again, it's so nice that we have all these different options here, but it's so important that we regularly check in with our patients, that we set their expectations correctly, and, if a patient isn't responding well, that we be sure we actually have the correct diagnosis and the correct reasons that they may not be responding well before we just cycle to another therapy.
Dr. Leuchars:
As we come to the end of our program, Dr. Sohn, do you have any final thoughts about optimizing diagnosis and treatment of psoriatic arthritis you'd like to share with our audience?
Dr. Sohn:
Again, I think it's so important that we be on the hunt for psoriatic arthritis in any of our patients with skin psoriasis, because it can manifest in different ways. It may be in the joints, in the DIPs, or in the PIPs. It may be in the spine. It may be in the soft tissues. It may be manifesting in a subclinical manner that, unless we spend some time really discussing this with our patients, we may be missing it. We had mentioned before that a delay in diagnosis by as little as six months can actually lead to irreversible damage and further impacts on that patient's quality of life, the pain they experience, and even the fatigue they have.
Dr. Leuchars:
With those takeaways in mind, I want to thank my guest, Dr. Bret Sohn, for joining me to explore how we can overcome common barriers in psoriatic arthritis care. Dr. Sohn, it was a pleasure speaking with you.
Dr. Sohn:
Thank you so much for having me. I really appreciate that. Take care.
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