For patients who struggle with moderate to severe psoriasis, the notion that a potentially more debilitating disease, psoriatic arthritis, may be progressing in tandem may not even make the visit “agenda” when the patient shows up at the dermatologist’s office.
But it should — for two reasons: Undetected or untreated inflammatory arthritis can cause irreversible, possibly disabling damage to joints, and evolving biologic therapies that treat both psoriasis and psoriatic arthritis successfully offer unprecedented opportunities for effective management of both conditions.
Underdiagnosed and Undertreated
Psoriatic arthritis affected 1.31 million people in North America in 2004, according to a Frost & Sullivan report of primary care physicians and dermatologists.
The 2005 report “North American Psoriasis and Psoriatic Arthritis Markets” estimated that the number of people afflicted with psoriatic arthritis in North America will reach 1.4 million by 2011.
Yet, the report also noted that psoriatic arthritis is an underdiagnosed and undertreated condition — a finding that’s supported by physicians interviewed for this article.
The Frost & Sullivan report noted that in 2004 only 40% of psoriatic arthritis cases were diagnosed — or 0.52 million people. Of those, 66% were treated, or 0.35 million people.
The question, then, is this: Who should assume primary management of suspected psoriatic arthritis — the dermatologist or the rheumatologist?
No Easy Answer
There’s no easy answer, but the best approach is to let patient-reported symptom severity be the guide, according to Andrew Blauvelt, M.D., Chief of the Dermatology Service at the VA Medical Center in Portland, OR. “My philosophy is that if the primary system or complaint is joint pain, the patient should be seen by the rheumatologist and followed for that primary problem,” says Dr. Blauvelt, Professor of Medicine at Oregon Health & Science University. “But if the patient has a fair amount of skin disease and only minor joint issues, I might not send him to the rheumatologist but instead will favor using a drug that will treat both.”
Rheumatologist Gregory Gardner, M.D., Professor of Medicine at the University of Washington in Seattle, proposes a similar approach. “Who does most of the management depends on the predominant issue: Is it mostly psoriasis with a little bit of arthritis, or mostly arthritis with a bit of psoriasis?” he says. “In my experience, it usually tends to present in one of those two ways — but sometimes people have both bad skin and bad joints.”
For those patients, because of the long-term potential for severe joint damage, Dr. Gardner takes the aggressive route — putting patients on methotrexate early on and then adding a tumor necrosis factor (TNF) inhibitor. “About 70% of patients respond [to the biologics], but often the joints respond a little better than the skin does, so that’s where the dermatologist’s management becomes particularly important,” Dr. Gardner says, in modifying dosages and adding other therapies such as topicals.
One issue, of course, is that psoriatic arthritis cases don’t necessarily present in such a “slam-dunk” manner — and the co-morbid arthritis may not be picked up until possibly avoidable joint damage has already occurred.
Likewise, some patients in whom both conditions are problematic may present to both a dermatologist and a rheumatologist, increasing the potential for toxic medication regimens or dangerous dosing.
“Four-Quadrant Model” for Psoriatic Arthritis
To avoid the poor outcomes associated with either situation, psoriatic arthritis specialists are calling for a more concerted interdisciplinary approach — one that focuses on the natural history of both the skin and joint aspects of the disease. In their recent article this year in a March supplement to the Journal of the American Academy of Dermatology, Illinois dermatologist Kenneth Gordon, M.D., and rheumatologist Eric Ruderman, M.D., both affiliated with Northwestern University, call for a conceptual approach that considers each patient individually and takes into account several variables whose relative import directs the treatment plan. In essence, the authors support a co-management or primary management approach that addresses both acute manifestations and long-term impact of psoriatic arthritis.
The “four-quadrant model” the authors propose attempts to classify patients in four broad categories for the purpose of guiding therapeutic decision-making.
These categories include:
1. limited psoriasis/mild psoriatic arthritis
2. extensive psoriasis/mild psoriatic arthritis
3. limited psoriasis/progressive psoriatic arthritis
4. extensive psoriasis/progressive psoriatic arthritis.
In the first scenario, symptom minimization may be accomplished with topicals or phototherapy for the skin and NSAIDs or older standard drugs such as sulfasalazine for the joints.
For patients in the second quadrant, the therapeutic focus would be on psoriasis control with systemic drugs and NSAIDs for the arthritis symptoms.
Those who fall into the third quadrant might be considered candidates for either methotrexate or anti-TNF agents such as adalimumab (Humira), etanercept (Enbrel), or infliximab (Remicade), or with topicals or phototherapy as needed for residual skin issues.
Somewhat ironically, Drs. Gordon and Ruderman make the case that therapeutic decisions are perhaps easiest to make for patients in
the fourth quadrant — where TNF agents, alone or in combination with methotrexate, may emerge as the most effective approach.
Dermatologists should remember, Dr. Blauvelt cautions, that the new biologics are all associated with potentially serious side effects — rare cases of multiple sclerosis onset or lupus-like syndrome have been reported, and TNF inhibitors can exacerbate heart failure and elevate liver enzymes. The latter effect, though readily reversible, should be assessed twice annually, he adds.
As a final reminder, order a tuberculosis skin test for any patient who will be started on TNF inhibitors, Dr. Gardner notes, because of the potential for onset of the virulent military form of TB with the drugs’ use.
When to Refer? Err on Side of Caution
Steven Feldman, M.D., Ph.D., Professor of Dermatology, Pathology and Public Health at Wake Forest University School of Medicine, in Winston-Salem, N.C., gives his vote to either active dermatologist-rheumatologist co-management or at least a rheumatologist referral for assessment of the joints.
“When we see psoriasis patients, we ought to be asking regularly whether they’re having joint stiffness or tenderness,” he says. “Even if the joint issues are mild and we put the patient on Motrin, we should still refer to a rheumatologist for evaluation.” The point, Dr. Feldman maintains, is that even though joint pain may improve on NSAIDs, that “doesn’t mean the patient isn’t losing range of motion or that there aren’t destructive changes on X-ray.”
That damage, experts contend, is potentially avoidable or even partially reversible with the new drugs — underlining the importance of assessment even if psoriatic arthritis symptoms are mild or joints appear normal on examination.
“Current therapeutics allow complete control to a remission-like state in some patients with [inflammatory] arthritis. Basically, stopping progression of damage — as seen on X-ray — means less load of damage throughout patients’ lives,” Kathryn Hobbs, M.D., Associate Clinical Professor of Medicine at the University of Colorado Health Sciences Center in Denver and Administrative Director of the Clinical Trials Unit at Denver Arthritis Clinic, advises.
More Important than Ever to Manage
How best to manage — or co-manage — patients with psoriatic arthritis has become more pressing in recent years, in part because of increased awareness of the disease. It was formerly thought that only approximately 10% of patients with psoriasis went on to develop psoriatic arthritis, but that estimate has been revised upward in recent years. As awareness of psoriatic arthritis has grown and targeted treatment options have increased with the advent of the new biologics, diagnosis rates have risen almost in tandem, according to Dr. Blauvelt.
“It’s now believed that about one-third of psoriasis patients will develop psoriatic arthritis, so it’s much more commonly diagnosed than it used to be,” he says. “I think that reflects more knowledge about and more study of PsA with the newer biologics.”
In fact, OHSU has a new multidisciplinary center devoted specifically to the disease, Dr. Blauvelt says. The Center of Excellence in Psoriasis and Psoriatic Arthritis (CEPPA), which opens this month, is staffed by not just dermatologists and rheumatologists but also by psychiatrists and allied health professionals.
Too Few Rheumatologists
Most dermatologists who treat patients with psoriatic arthritis whose joint disease may be worsening would not think twice about referring to a rheumatologist. The issue, of late, is whether that specialist is either available in the community or prepared to take on new patients. The current shortage of rheumatologists (even though it’s region-dependent and some urban areas have adequate numbers, it’s acute in some parts of the country) is hindering timely referrals. The American College of Rheumatology in 1990 called for 6,500 rheumatologists by 2000 to a predicted 70 million U.S. adults with joint problems. The supply 6 years ago was only about half that, according to ACR and Arthritis Foundation reports.
And some dermatologists are feeling that shortage when they try to refer.
“I have a rheumatologist colleague one floor away, so it’s easier for me,” Dr. Blauvelt says. “But some dermatologists have no rheumatologists available in their communities.”
That’s the frustration Omaha, NE, dermatologist Joel Schlessinger, M.D., frequently experiences. “In academia it is much easier to send a patient down the hall for a consult with the rheumatologist on the date of the initial visit,” he says. “This is much more challenging in private practice, where this may take weeks or longer.”
When that situation arises, a bit of cajoling, or even creativity, may be in order. For his part, Dr. Feldman urges dermatologists to make the phone call directly and stress that the patient they’d like to refer may have psoriatic arthritis. (The point is that rheumatologists are often overwhelmed with osteoarthritis patients, but may be excited by the prospect of treating patients for whom the newer agents will confer major quality-of-life benefits.)
“There really aren’t enough rheumatologists to go around, so it’s hard to get patients in unless they have inflammatory arthritis — rheumatologists take care of patients who have bad osteoarthritis all day and can’t help them much,” he explains. “But they really like seeing patients with inflammatory arthritis because they have great drugs than can turn it around.” Dr. Feldman’s prediction is that if the dermatologist calls for help with psoriatic arthritis patients, the rheumatologist will “work them in.”
Barring that possibility, even a telephone consult with a rheumatologist can get the ball rolling and the patient en route to effective treatment, Dr. Hobbs notes, and vice versa if it’s a dermatologist shortage.
“In many areas there is a long wait to get in to see one, or either, of the specialists, in which case [treatment] can be started with a telephone consult,” she says. “That can at least get the process moving, and it’s better than waiting.”
Increasing Your Treatment Comfort Level
The rheumatologist shortage may provide impetus for dermatologists to become more comfortable treating patients’ minor joint pain, Dr. Blauvelt says, “because they can. A psoriasis patient with some joint pain doesn’t automatically need to see a rheumatologist right away. I encourage them to manage those patients with a TNF agent.”
Dr. Schlessinger concurs in principle with Dr. Blauvelt, but says that since he can’t measure treatment response in the joints beyond what patients report, he’s inclined to refer them periodically. “Since the advent of biologics, I feel much more comfortable managing these patients from a psoriasis standpoint; [yet] I feel it is very important they see a rheumatologist at least once yearly for labwork assessments and any other recommendations,” he says.
For patients who struggle with moderate to severe psoriasis, the notion that a potentially more debilitating disease, psoriatic arthritis, may be progressing in tandem may not even make the visit “agenda” when the patient shows up at the dermatologist’s office.
But it should — for two reasons: Undetected or untreated inflammatory arthritis can cause irreversible, possibly disabling damage to joints, and evolving biologic therapies that treat both psoriasis and psoriatic arthritis successfully offer unprecedented opportunities for effective management of both conditions.
Underdiagnosed and Undertreated
Psoriatic arthritis affected 1.31 million people in North America in 2004, according to a Frost & Sullivan report of primary care physicians and dermatologists.
The 2005 report “North American Psoriasis and Psoriatic Arthritis Markets” estimated that the number of people afflicted with psoriatic arthritis in North America will reach 1.4 million by 2011.
Yet, the report also noted that psoriatic arthritis is an underdiagnosed and undertreated condition — a finding that’s supported by physicians interviewed for this article.
The Frost & Sullivan report noted that in 2004 only 40% of psoriatic arthritis cases were diagnosed — or 0.52 million people. Of those, 66% were treated, or 0.35 million people.
The question, then, is this: Who should assume primary management of suspected psoriatic arthritis — the dermatologist or the rheumatologist?
No Easy Answer
There’s no easy answer, but the best approach is to let patient-reported symptom severity be the guide, according to Andrew Blauvelt, M.D., Chief of the Dermatology Service at the VA Medical Center in Portland, OR. “My philosophy is that if the primary system or complaint is joint pain, the patient should be seen by the rheumatologist and followed for that primary problem,” says Dr. Blauvelt, Professor of Medicine at Oregon Health & Science University. “But if the patient has a fair amount of skin disease and only minor joint issues, I might not send him to the rheumatologist but instead will favor using a drug that will treat both.”
Rheumatologist Gregory Gardner, M.D., Professor of Medicine at the University of Washington in Seattle, proposes a similar approach. “Who does most of the management depends on the predominant issue: Is it mostly psoriasis with a little bit of arthritis, or mostly arthritis with a bit of psoriasis?” he says. “In my experience, it usually tends to present in one of those two ways — but sometimes people have both bad skin and bad joints.”
For those patients, because of the long-term potential for severe joint damage, Dr. Gardner takes the aggressive route — putting patients on methotrexate early on and then adding a tumor necrosis factor (TNF) inhibitor. “About 70% of patients respond [to the biologics], but often the joints respond a little better than the skin does, so that’s where the dermatologist’s management becomes particularly important,” Dr. Gardner says, in modifying dosages and adding other therapies such as topicals.
One issue, of course, is that psoriatic arthritis cases don’t necessarily present in such a “slam-dunk” manner — and the co-morbid arthritis may not be picked up until possibly avoidable joint damage has already occurred.
Likewise, some patients in whom both conditions are problematic may present to both a dermatologist and a rheumatologist, increasing the potential for toxic medication regimens or dangerous dosing.
“Four-Quadrant Model” for Psoriatic Arthritis
To avoid the poor outcomes associated with either situation, psoriatic arthritis specialists are calling for a more concerted interdisciplinary approach — one that focuses on the natural history of both the skin and joint aspects of the disease. In their recent article this year in a March supplement to the Journal of the American Academy of Dermatology, Illinois dermatologist Kenneth Gordon, M.D., and rheumatologist Eric Ruderman, M.D., both affiliated with Northwestern University, call for a conceptual approach that considers each patient individually and takes into account several variables whose relative import directs the treatment plan. In essence, the authors support a co-management or primary management approach that addresses both acute manifestations and long-term impact of psoriatic arthritis.
The “four-quadrant model” the authors propose attempts to classify patients in four broad categories for the purpose of guiding therapeutic decision-making.
These categories include:
1. limited psoriasis/mild psoriatic arthritis
2. extensive psoriasis/mild psoriatic arthritis
3. limited psoriasis/progressive psoriatic arthritis
4. extensive psoriasis/progressive psoriatic arthritis.
In the first scenario, symptom minimization may be accomplished with topicals or phototherapy for the skin and NSAIDs or older standard drugs such as sulfasalazine for the joints.
For patients in the second quadrant, the therapeutic focus would be on psoriasis control with systemic drugs and NSAIDs for the arthritis symptoms.
Those who fall into the third quadrant might be considered candidates for either methotrexate or anti-TNF agents such as adalimumab (Humira), etanercept (Enbrel), or infliximab (Remicade), or with topicals or phototherapy as needed for residual skin issues.
Somewhat ironically, Drs. Gordon and Ruderman make the case that therapeutic decisions are perhaps easiest to make for patients in
the fourth quadrant — where TNF agents, alone or in combination with methotrexate, may emerge as the most effective approach.
Dermatologists should remember, Dr. Blauvelt cautions, that the new biologics are all associated with potentially serious side effects — rare cases of multiple sclerosis onset or lupus-like syndrome have been reported, and TNF inhibitors can exacerbate heart failure and elevate liver enzymes. The latter effect, though readily reversible, should be assessed twice annually, he adds.
As a final reminder, order a tuberculosis skin test for any patient who will be started on TNF inhibitors, Dr. Gardner notes, because of the potential for onset of the virulent military form of TB with the drugs’ use.
When to Refer? Err on Side of Caution
Steven Feldman, M.D., Ph.D., Professor of Dermatology, Pathology and Public Health at Wake Forest University School of Medicine, in Winston-Salem, N.C., gives his vote to either active dermatologist-rheumatologist co-management or at least a rheumatologist referral for assessment of the joints.
“When we see psoriasis patients, we ought to be asking regularly whether they’re having joint stiffness or tenderness,” he says. “Even if the joint issues are mild and we put the patient on Motrin, we should still refer to a rheumatologist for evaluation.” The point, Dr. Feldman maintains, is that even though joint pain may improve on NSAIDs, that “doesn’t mean the patient isn’t losing range of motion or that there aren’t destructive changes on X-ray.”
That damage, experts contend, is potentially avoidable or even partially reversible with the new drugs — underlining the importance of assessment even if psoriatic arthritis symptoms are mild or joints appear normal on examination.
“Current therapeutics allow complete control to a remission-like state in some patients with [inflammatory] arthritis. Basically, stopping progression of damage — as seen on X-ray — means less load of damage throughout patients’ lives,” Kathryn Hobbs, M.D., Associate Clinical Professor of Medicine at the University of Colorado Health Sciences Center in Denver and Administrative Director of the Clinical Trials Unit at Denver Arthritis Clinic, advises.
More Important than Ever to Manage
How best to manage — or co-manage — patients with psoriatic arthritis has become more pressing in recent years, in part because of increased awareness of the disease. It was formerly thought that only approximately 10% of patients with psoriasis went on to develop psoriatic arthritis, but that estimate has been revised upward in recent years. As awareness of psoriatic arthritis has grown and targeted treatment options have increased with the advent of the new biologics, diagnosis rates have risen almost in tandem, according to Dr. Blauvelt.
“It’s now believed that about one-third of psoriasis patients will develop psoriatic arthritis, so it’s much more commonly diagnosed than it used to be,” he says. “I think that reflects more knowledge about and more study of PsA with the newer biologics.”
In fact, OHSU has a new multidisciplinary center devoted specifically to the disease, Dr. Blauvelt says. The Center of Excellence in Psoriasis and Psoriatic Arthritis (CEPPA), which opens this month, is staffed by not just dermatologists and rheumatologists but also by psychiatrists and allied health professionals.
Too Few Rheumatologists
Most dermatologists who treat patients with psoriatic arthritis whose joint disease may be worsening would not think twice about referring to a rheumatologist. The issue, of late, is whether that specialist is either available in the community or prepared to take on new patients. The current shortage of rheumatologists (even though it’s region-dependent and some urban areas have adequate numbers, it’s acute in some parts of the country) is hindering timely referrals. The American College of Rheumatology in 1990 called for 6,500 rheumatologists by 2000 to a predicted 70 million U.S. adults with joint problems. The supply 6 years ago was only about half that, according to ACR and Arthritis Foundation reports.
And some dermatologists are feeling that shortage when they try to refer.
“I have a rheumatologist colleague one floor away, so it’s easier for me,” Dr. Blauvelt says. “But some dermatologists have no rheumatologists available in their communities.”
That’s the frustration Omaha, NE, dermatologist Joel Schlessinger, M.D., frequently experiences. “In academia it is much easier to send a patient down the hall for a consult with the rheumatologist on the date of the initial visit,” he says. “This is much more challenging in private practice, where this may take weeks or longer.”
When that situation arises, a bit of cajoling, or even creativity, may be in order. For his part, Dr. Feldman urges dermatologists to make the phone call directly and stress that the patient they’d like to refer may have psoriatic arthritis. (The point is that rheumatologists are often overwhelmed with osteoarthritis patients, but may be excited by the prospect of treating patients for whom the newer agents will confer major quality-of-life benefits.)
“There really aren’t enough rheumatologists to go around, so it’s hard to get patients in unless they have inflammatory arthritis — rheumatologists take care of patients who have bad osteoarthritis all day and can’t help them much,” he explains. “But they really like seeing patients with inflammatory arthritis because they have great drugs than can turn it around.” Dr. Feldman’s prediction is that if the dermatologist calls for help with psoriatic arthritis patients, the rheumatologist will “work them in.”
Barring that possibility, even a telephone consult with a rheumatologist can get the ball rolling and the patient en route to effective treatment, Dr. Hobbs notes, and vice versa if it’s a dermatologist shortage.
“In many areas there is a long wait to get in to see one, or either, of the specialists, in which case [treatment] can be started with a telephone consult,” she says. “That can at least get the process moving, and it’s better than waiting.”
Increasing Your Treatment Comfort Level
The rheumatologist shortage may provide impetus for dermatologists to become more comfortable treating patients’ minor joint pain, Dr. Blauvelt says, “because they can. A psoriasis patient with some joint pain doesn’t automatically need to see a rheumatologist right away. I encourage them to manage those patients with a TNF agent.”
Dr. Schlessinger concurs in principle with Dr. Blauvelt, but says that since he can’t measure treatment response in the joints beyond what patients report, he’s inclined to refer them periodically. “Since the advent of biologics, I feel much more comfortable managing these patients from a psoriasis standpoint; [yet] I feel it is very important they see a rheumatologist at least once yearly for labwork assessments and any other recommendations,” he says.
For patients who struggle with moderate to severe psoriasis, the notion that a potentially more debilitating disease, psoriatic arthritis, may be progressing in tandem may not even make the visit “agenda” when the patient shows up at the dermatologist’s office.
But it should — for two reasons: Undetected or untreated inflammatory arthritis can cause irreversible, possibly disabling damage to joints, and evolving biologic therapies that treat both psoriasis and psoriatic arthritis successfully offer unprecedented opportunities for effective management of both conditions.
Underdiagnosed and Undertreated
Psoriatic arthritis affected 1.31 million people in North America in 2004, according to a Frost & Sullivan report of primary care physicians and dermatologists.
The 2005 report “North American Psoriasis and Psoriatic Arthritis Markets” estimated that the number of people afflicted with psoriatic arthritis in North America will reach 1.4 million by 2011.
Yet, the report also noted that psoriatic arthritis is an underdiagnosed and undertreated condition — a finding that’s supported by physicians interviewed for this article.
The Frost & Sullivan report noted that in 2004 only 40% of psoriatic arthritis cases were diagnosed — or 0.52 million people. Of those, 66% were treated, or 0.35 million people.
The question, then, is this: Who should assume primary management of suspected psoriatic arthritis — the dermatologist or the rheumatologist?
No Easy Answer
There’s no easy answer, but the best approach is to let patient-reported symptom severity be the guide, according to Andrew Blauvelt, M.D., Chief of the Dermatology Service at the VA Medical Center in Portland, OR. “My philosophy is that if the primary system or complaint is joint pain, the patient should be seen by the rheumatologist and followed for that primary problem,” says Dr. Blauvelt, Professor of Medicine at Oregon Health & Science University. “But if the patient has a fair amount of skin disease and only minor joint issues, I might not send him to the rheumatologist but instead will favor using a drug that will treat both.”
Rheumatologist Gregory Gardner, M.D., Professor of Medicine at the University of Washington in Seattle, proposes a similar approach. “Who does most of the management depends on the predominant issue: Is it mostly psoriasis with a little bit of arthritis, or mostly arthritis with a bit of psoriasis?” he says. “In my experience, it usually tends to present in one of those two ways — but sometimes people have both bad skin and bad joints.”
For those patients, because of the long-term potential for severe joint damage, Dr. Gardner takes the aggressive route — putting patients on methotrexate early on and then adding a tumor necrosis factor (TNF) inhibitor. “About 70% of patients respond [to the biologics], but often the joints respond a little better than the skin does, so that’s where the dermatologist’s management becomes particularly important,” Dr. Gardner says, in modifying dosages and adding other therapies such as topicals.
One issue, of course, is that psoriatic arthritis cases don’t necessarily present in such a “slam-dunk” manner — and the co-morbid arthritis may not be picked up until possibly avoidable joint damage has already occurred.
Likewise, some patients in whom both conditions are problematic may present to both a dermatologist and a rheumatologist, increasing the potential for toxic medication regimens or dangerous dosing.
“Four-Quadrant Model” for Psoriatic Arthritis
To avoid the poor outcomes associated with either situation, psoriatic arthritis specialists are calling for a more concerted interdisciplinary approach — one that focuses on the natural history of both the skin and joint aspects of the disease. In their recent article this year in a March supplement to the Journal of the American Academy of Dermatology, Illinois dermatologist Kenneth Gordon, M.D., and rheumatologist Eric Ruderman, M.D., both affiliated with Northwestern University, call for a conceptual approach that considers each patient individually and takes into account several variables whose relative import directs the treatment plan. In essence, the authors support a co-management or primary management approach that addresses both acute manifestations and long-term impact of psoriatic arthritis.
The “four-quadrant model” the authors propose attempts to classify patients in four broad categories for the purpose of guiding therapeutic decision-making.
These categories include:
1. limited psoriasis/mild psoriatic arthritis
2. extensive psoriasis/mild psoriatic arthritis
3. limited psoriasis/progressive psoriatic arthritis
4. extensive psoriasis/progressive psoriatic arthritis.
In the first scenario, symptom minimization may be accomplished with topicals or phototherapy for the skin and NSAIDs or older standard drugs such as sulfasalazine for the joints.
For patients in the second quadrant, the therapeutic focus would be on psoriasis control with systemic drugs and NSAIDs for the arthritis symptoms.
Those who fall into the third quadrant might be considered candidates for either methotrexate or anti-TNF agents such as adalimumab (Humira), etanercept (Enbrel), or infliximab (Remicade), or with topicals or phototherapy as needed for residual skin issues.
Somewhat ironically, Drs. Gordon and Ruderman make the case that therapeutic decisions are perhaps easiest to make for patients in
the fourth quadrant — where TNF agents, alone or in combination with methotrexate, may emerge as the most effective approach.
Dermatologists should remember, Dr. Blauvelt cautions, that the new biologics are all associated with potentially serious side effects — rare cases of multiple sclerosis onset or lupus-like syndrome have been reported, and TNF inhibitors can exacerbate heart failure and elevate liver enzymes. The latter effect, though readily reversible, should be assessed twice annually, he adds.
As a final reminder, order a tuberculosis skin test for any patient who will be started on TNF inhibitors, Dr. Gardner notes, because of the potential for onset of the virulent military form of TB with the drugs’ use.
When to Refer? Err on Side of Caution
Steven Feldman, M.D., Ph.D., Professor of Dermatology, Pathology and Public Health at Wake Forest University School of Medicine, in Winston-Salem, N.C., gives his vote to either active dermatologist-rheumatologist co-management or at least a rheumatologist referral for assessment of the joints.
“When we see psoriasis patients, we ought to be asking regularly whether they’re having joint stiffness or tenderness,” he says. “Even if the joint issues are mild and we put the patient on Motrin, we should still refer to a rheumatologist for evaluation.” The point, Dr. Feldman maintains, is that even though joint pain may improve on NSAIDs, that “doesn’t mean the patient isn’t losing range of motion or that there aren’t destructive changes on X-ray.”
That damage, experts contend, is potentially avoidable or even partially reversible with the new drugs — underlining the importance of assessment even if psoriatic arthritis symptoms are mild or joints appear normal on examination.
“Current therapeutics allow complete control to a remission-like state in some patients with [inflammatory] arthritis. Basically, stopping progression of damage — as seen on X-ray — means less load of damage throughout patients’ lives,” Kathryn Hobbs, M.D., Associate Clinical Professor of Medicine at the University of Colorado Health Sciences Center in Denver and Administrative Director of the Clinical Trials Unit at Denver Arthritis Clinic, advises.
More Important than Ever to Manage
How best to manage — or co-manage — patients with psoriatic arthritis has become more pressing in recent years, in part because of increased awareness of the disease. It was formerly thought that only approximately 10% of patients with psoriasis went on to develop psoriatic arthritis, but that estimate has been revised upward in recent years. As awareness of psoriatic arthritis has grown and targeted treatment options have increased with the advent of the new biologics, diagnosis rates have risen almost in tandem, according to Dr. Blauvelt.
“It’s now believed that about one-third of psoriasis patients will develop psoriatic arthritis, so it’s much more commonly diagnosed than it used to be,” he says. “I think that reflects more knowledge about and more study of PsA with the newer biologics.”
In fact, OHSU has a new multidisciplinary center devoted specifically to the disease, Dr. Blauvelt says. The Center of Excellence in Psoriasis and Psoriatic Arthritis (CEPPA), which opens this month, is staffed by not just dermatologists and rheumatologists but also by psychiatrists and allied health professionals.
Too Few Rheumatologists
Most dermatologists who treat patients with psoriatic arthritis whose joint disease may be worsening would not think twice about referring to a rheumatologist. The issue, of late, is whether that specialist is either available in the community or prepared to take on new patients. The current shortage of rheumatologists (even though it’s region-dependent and some urban areas have adequate numbers, it’s acute in some parts of the country) is hindering timely referrals. The American College of Rheumatology in 1990 called for 6,500 rheumatologists by 2000 to a predicted 70 million U.S. adults with joint problems. The supply 6 years ago was only about half that, according to ACR and Arthritis Foundation reports.
And some dermatologists are feeling that shortage when they try to refer.
“I have a rheumatologist colleague one floor away, so it’s easier for me,” Dr. Blauvelt says. “But some dermatologists have no rheumatologists available in their communities.”
That’s the frustration Omaha, NE, dermatologist Joel Schlessinger, M.D., frequently experiences. “In academia it is much easier to send a patient down the hall for a consult with the rheumatologist on the date of the initial visit,” he says. “This is much more challenging in private practice, where this may take weeks or longer.”
When that situation arises, a bit of cajoling, or even creativity, may be in order. For his part, Dr. Feldman urges dermatologists to make the phone call directly and stress that the patient they’d like to refer may have psoriatic arthritis. (The point is that rheumatologists are often overwhelmed with osteoarthritis patients, but may be excited by the prospect of treating patients for whom the newer agents will confer major quality-of-life benefits.)
“There really aren’t enough rheumatologists to go around, so it’s hard to get patients in unless they have inflammatory arthritis — rheumatologists take care of patients who have bad osteoarthritis all day and can’t help them much,” he explains. “But they really like seeing patients with inflammatory arthritis because they have great drugs than can turn it around.” Dr. Feldman’s prediction is that if the dermatologist calls for help with psoriatic arthritis patients, the rheumatologist will “work them in.”
Barring that possibility, even a telephone consult with a rheumatologist can get the ball rolling and the patient en route to effective treatment, Dr. Hobbs notes, and vice versa if it’s a dermatologist shortage.
“In many areas there is a long wait to get in to see one, or either, of the specialists, in which case [treatment] can be started with a telephone consult,” she says. “That can at least get the process moving, and it’s better than waiting.”
Increasing Your Treatment Comfort Level
The rheumatologist shortage may provide impetus for dermatologists to become more comfortable treating patients’ minor joint pain, Dr. Blauvelt says, “because they can. A psoriasis patient with some joint pain doesn’t automatically need to see a rheumatologist right away. I encourage them to manage those patients with a TNF agent.”
Dr. Schlessinger concurs in principle with Dr. Blauvelt, but says that since he can’t measure treatment response in the joints beyond what patients report, he’s inclined to refer them periodically. “Since the advent of biologics, I feel much more comfortable managing these patients from a psoriasis standpoint; [yet] I feel it is very important they see a rheumatologist at least once yearly for labwork assessments and any other recommendations,” he says.
