The Evolving Spectrum of TNF Inhibitors in the Management of Psoriatic Disease - Episode 4
Mark G. Lebwohl, MD, and Joseph F. Merola, MD, MMSc, provide tips to overcome diagnostic delay in psoriasis.
Mark G. Lebwohl, MD: I agree completely that the diagnostic delay leads to more joint damage. In the long run, it’s harder to control psoriatic arthritis [PsA]. That’s recently been shown even for psoriasis with some of the newer agents that we have. For psoriatic arthritis, it was shown years ago that the later you start therapy, the harder it is to control. How do you think we can overcome that? Is there anything we can do to ensure a timely diagnosis?
Joseph F. Merola, MD, MMSc: Yes, regular screening. We’re asked how frequently we should be screening. It’s a quick and easy thing to do. I recommend screening at every visit, at least every 6 months in these patients. Whenever we see a patient with psoriasis, regular screening makes sense, increasing awareness as we’re doing among physicians but also among patients. Patients should be aware, and many organizations are doing that. We can do that as well. We counsel our patients with psoriasis that they’re at risk, so they should let us know if they’re experiencing new-onset musculoskeletal symptoms, joint symptoms, etc.
Years ago, we published a PsA mnemonic. It’s not a formalized screening tool, but I love to teach my colleagues about this because it’s easier to remember PsA. Ask about P, pain. You want to qualify that with stiffness. Do they have prolonged stiffness that lasts more than 20 or 30 min? That might suggest inflammatory arthritis. There are a couple of other Ss in there. One S is for sausage—dactylitis that Mark mentioned. That’s specific to psoriatic arthritis. Another is swelling. Those are going to make you think more about inflammatory arthritis. A is for axial disease. Ask if they have inflammatory type back pain. Do they have back pain that improves with activity? That’s something that’s occurring more, maybe in a younger patient where you might expect less likely to be seeing inflammatory back pain. PsA is easy to remember.
We do have more formal screening tools. For example, we have the pest screening tool. It’s a simple 5-question tool that’s very easy on the dermatologist and on the office because it’s patient-facing. It’s something a patient can complete in the waiting room. While they’re waiting to see you, it could be pushed to them through a gateway if you have an electronic patient gateway for them to complete. If it’s positive, you can decide how much of it you want to own. It could facilitate a discussion about psoriatic arthritis, or it could be simply, “You’ve screened positive, and I’m going to refer you to 1 of my rheumatology colleagues to take a deeper dive.” It’s very easy, it’s a low burden on the office. Increasingly, my colleagues are aware of this. It’s really about the question, “Once the patient screens positive, what do I do with it?” We can talk about this more, but we dermatologists can increasingly get comfortable with the diagnosis.
Mark made a beautiful comment a few moments ago that sometimes he does a diagnostic therapeutic maneuver. If my suspicions are high enough, if I’m choosing an agent that I know can treat psoriatic arthritis, I’m going to treat them. I’m going to have that conversation with the patient if my suspicions are high that they have PsA. When they come back, we’re going to say, “How do you feel? How have your symptoms changed?” That’s 1 approach. Another is to refer to the rheumatologist if you think they can get there a timely manner. We have a lot of interest in this. Years ago, we developed a group called PPACMAN [Psoriasis & Psoriatic Arthritis Clinics Multicenter Advancement Network], which looks at setting up facilitated referral networks or minimally setting up facilitated communication between dermatologists and rheumatologists so we can phone a friend, send an email, get a patient in sooner, or have an offline chat about the right thing for this patient in front of us. All of that is to avoid the delays in treatment and become, over time, more confident in diagnosis and treatment that gets the patient to the right therapy.
Mark, I’d like to hear your reflections on that. I unpacked a lot, but screening is key. What do you think, from a dermatologist’s perspective, about dermatologists getting more confident and comfortable with diagnosis and treatment? We’re talking about a variety of MOAs [mechanisms of action], of treatment, facing psoriasis and psoriatic arthritis. Why not choose 1 of those at a juncture when you think your patient has PsA and see what happens? How do you train your residents and our colleagues about that?
Mark G. Lebwohl, MD: Of the treatments we use for psoriatic arthritis, it turns out they work really well for psoriasis too. If there’s even a suspicion it’s worth using 1 of the treatments we mentioned already: TNF [tumor necrosis factor] alpha-blockers, IL-17 blockers, and JAK inhibitors. The JAK inhibitors are not approved for psoriasis, but they work quite well. Any would be useful if you think the patient has psoriatic arthritis. The JAK inhibitors have some boxed warnings, so it’s suggested that they might follow other treatments. They won’t necessarily be the first treatment you use, but they’re quite effective.
One thing we all agree on is that you should ask a patient when you see them, “How are your joints? Do they hurt? Are they stiff?” That’s an easy question. It takes almost no time and dermatologists are pressed for time. We’re being asked to see more patients in less time, but that’s an easy question. It has a profound impact on the treatment of your patient. It’s worth asking that question at every visit because I said already 70% of the time, psoriasis proceeds to arthritis. So, when you end up with the diagnosis of psoriatic arthritis, most of the time it’s going to occur after you first see that patient. It’s worth asking that question at every visit, assuming the visits are 6 months apart or something like that.
Joseph F. Merola, MD, MMSc: On the flip side, some of my colleagues get nervous about referring patients. I say, “I did the rheumatology half of my training for a reason. That’s what we’re there for.” If a patient is uncomfortable, they have musculoskeletal pain. It’s unclear. That’s why we want to see them, so please refer them. We can take a deep dive, and there’s nuance if we need to get plain films and sacroiliac joint x-rays for axial disease and other advanced imaging. We’re happy to do it, so send them. That’s always a good take-home point.
Transcript edited for clarity