Guidelines for Psoriatic Arthritis Provide Standards of Care
Recommendations address screening for cardiovascular disease, eye problems and other common comorbidities.
Guidelines aimed at educating doctors about the need to screen patients with psoriatic arthritis for conditions that often accompany the disease are helping increase awareness that the chronic, inflammatory arthritis affects more than just skin and joints.
The set of guidelines, the first on the subject, was drafted in 2014 as a way to provide evidence that doctors need to be more aware that comorbidities for psoriatic arthritis have been underappreciated and underreported.
Elaine Husni, MD, director of the Arthritis and Musculoskeletal Center at the Cleveland Clinic headed the group that drafted the guidelines at a joint meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the Spondyloarthritis Research and Treatment Network (SPARTAN) in New York. The guidelines were then submitted to The Journal of Rheumatology where they were the focus of a peer review process before being published in 2014.
In a follow-up article published in March 2015 in Current Opinion in Rheumatology, Dr. Husni said clinicians should be aware of how comorbidities affect people with PsA and the best way to manage those coexisting diseases.
“What really is important is to treat the patient as a whole and to say there are associated conditions that are more common in people with psoriatic arthritis, and physicians treating these patients should be made aware,” she explains.
Defining Psoriatic Arthritis
Psoriatic arthritis is an autoimmune type of arthritis that affects as many as 30 percent of patients with the chronic skin condition psoriasis. Generally, the arthritis appears several years after the onset of psoriasis, although in some cases it can appear before or at the same time the skin condition begins. In addition to psoriasis’ red, scaly rash, symptoms of psoriatic arthritis include painful and swollen joints, morning stiffness, reduced range of motion and general fatigue.
Psoriatic arthritis is classified as a spondyloarthropathy, a group of diseases with overlapping features. The diseases usually involve the spine, pelvis (sacroiliac joint) and entheses (the locations where ligaments and tendons attach to bone). They may also be associated with a particular gene called HLA-B27. Other spondyloarthropathies include ankylosing spondylitis, enteropathic arthritis (arthritis that is linked to inflammatory bowel diseases) and reactive arthritis.
Comorbidities Associated with PsA
Dr. Husni says recent research is now starting to reveal new information about broader health risks for patients in this group. Topping that list: cardiovascular disease. So the guidelines recommend all psoriatic arthritis patients be screened for it.
“We now know that cardiovascular disease is more prevalent [than in the general population],” says Dr. Husni. Although a sedentary lifestyle, obesity or treatment with corticosteroids may contribute to the risk, she says there are clearly disease-specific factors that can lead to heart disease. “So that tells us it’s the disease itself,” she says.
The guidelines also recommend screening for inflammatory bowel disease, as well as ophthalmic conditions, such as uveitis, because studies show a likely link with these conditions as well.
“A lot of people might not think that eye inflammation has anything to do with psoriatic arthritis. I think if we get the word out, doctors will start asking about it and patients will get help sooner and hopefully not suffer more damage,” Dr. Husni explains.
The guidelines also recommend patients be screened for obesity and diabetes. Furthermore, before starting a biologic or another immunosuppressant, it is recommended that patients get tested for infections like tuberculosis, HIV and hepatitis B and C – especially if they have additional risk factors.
Treating Comorbidities of PsA
Dr. Husni says while the guidelines include information on what medications are used to treat the various comorbidities, they don’t recommend particular treatments because there are a range of options and a variety of different types of doctors who might manage them. But she says she hopes that simply knowing what to look out for will help not only doctors but also patients.
“Patients need to know their symptoms could be related to psoriatic arthritis instead of thinking it is something else,” she says. “Patients will be more aware so they can tell their rheumatologist and get better comprehensive treatment as a whole. Like with any disease, if you treat all their symptoms they will do better than if you just treat one or two symptoms.”
David Pisetsky, MD, a professor of medicine at Duke University Medical Center in Durham, N.C. says he thinks most rheumatologists are aware of these comorbidities but agrees guidelines are helpful, especially when other types of doctors are overseeing patient care.
“Some people get seen by generalists, some by rheumatologists, and it’s good to have an organized approach to say what you should be concerned about for these patients,” he explains.
Dr. Pisetsky says it is also important to recognize that comorbidities can vary, depending on which of the five different subtypes of psoriatic arthritis a patient has.