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Arthritis Today

Many Psoriatic Arthritis Patients Are Undertreated

PsA patients often get inadequate help for their disease, even though effective treatment is available.

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About half of all patients with psoriasis and psoriatic arthritis (PsA) are dissatisfied with the treatment they are getting, and research shows many PsA patients are either undertreated or not getting any treatment at all.

Psoriasis – an autoimmune, inflammatory skin disease – causes patients to develop painful red, scaly rashes. Up to 30 percent of patients with psoriasis have or will develop psoriatic arthritis, in which the joints are also affected, causing pain, swelling and potential damage.

“Psoriatic arthritis is under-diagnosed and under-treated in clinical practice. As dermatologists, we need to continually educate ourselves regarding detection and treatment of PsA,” explains April W. Armstrong, MD, director of the Psoriasis Program for the Department of Dermatology at the University of Colorado. She is the lead author of a study published in 2013 in JAMA Dermatology.

“For people suffering from psoriatic arthritis, if they are unsatisfied with their treatments it’s often because they have noticeable symptoms. And that is something that is concerning because the symptoms they have often correlate with X­-ray findings for joint destruction. Once joint destruction occurs, it is irreversible.”

Treatment for PsA and psoriasis includes topical creams (applied to the skin), phototherapy (light therapy), oral drugs such as methotrexate, and/or biologics such as etanercept (Enbrel) and adalimumab (Humira). Research also shows the benefits of a treat to target strategy. This approach sets a goal for patients, such as low or no disease activity, and then monitors patients frequently and escalates treatment if necessary to help them reach that target.

Patients Untreated and Unsatisfied

In Dr. Armstrong’s study, researchers analyzed data from 13 surveys – conducted by the National Psoriasis Foundation between 2003 and 2011 – of 5,604 patients with psoriasis or PsA. The researchers found that, depending on the year the survey was taken, 23 to 49 percent of patients with mild and moderate psoriasis said they were untreated, and 9 and 30 percent of those with severe psoriasis said they were untreated.

Among those who were treated, 29.5 percent of patients with moderate psoriasis and 21.5 percent with severe psoriasis were using only topical treatments. According to respondents, the top three reasons for using only skin creams were, topicals have fewer side effects than other medications, their “disease is not serious enough” for other medications, and their doctor would not prescribe other treatments.

Overall, 45.5 percent of PsA patients and 52.3 percent of psoriasis patients reported they weren’t satisfied with their treatment. The study also found that when it came to biologics (used by approximately 30 percent of respondents at any one point in time), patients who discontinued them said they did so because of side effects, lack of effectiveness or inability to get insurance coverage for them.

Biologics Have Benefits, But Are Expensive

Christopher T. Ritchlin, MD, professor and chief of the division of allergy, immunology and rheumatology at the University of Rochester Medical Center in New York, is one of three co­founders of the hospital’s Psoriasis Center. He says in his clinical practice, discontinuation of biologics is rarely a result of ineffectiveness because most PsA patients respond to them at a rate that’s greater than what is typically seen with rheumatoid arthritis (RA) patients.

“I think biologics work well for patients with PsA because it’s a different disease than RA,” he says, adding that tumor necrosis factor (TNF) – the inflammatory molecule targeted by biologics like etanercept and adalimumab – may play a bigger role in PsA than in RA.

In fact, a study published in Arthritis Research & Therapy in 2010 shows remission is possible in PsA patients. The study saw a remission rate of more than 58 percent one year after anti-TNF therapy compared to 44 percent among RA patients.

But Dr. Ritchlin says it is increasingly common for patients to have difficulty getting insurance coverage for biologics, especially early in the disease. Many providers want physicians to first try less expensive treatments, such as methotrexate, even though Dr. Ritchlin says data shows they may not work as well for PsA.

He advises patients to keep an open line of communication with their doctor. “Talk with your dermatologist and rheumatologist about what is happening with your skin and joints, so things can be done to try to make it better.”

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