Goals of Therapy in Psoriasis and Psoriatic Arthritis



Anthony M. Turkiewicz, MD:Let’s go on to the dermatology side. Steve, talk to us about goals of therapy. Are there any factors that guide your selection in a patient with psoriasis, whether they have comorbidities, have tried therapy before, or have severity of skin involvement. Can you comment on that?

Steven R. Feldman, MD, PhD: On the skin side, my goal of therapy in patients with psoriasis and psoriatic arthritis is to make patients happy. The National Psoriasis Foundation has treatment target goals to get people completely clear with less than 1% of their body covered. But in my practice, if the patient is happy, I’m happy. My goal for psoriatic arthritis is for that to be controlled and for them not to have joint destruction, and I’m going to achieve that by sending them to 1 of you all to take care of them.

There are so many treatments for the skin that it’s hard to choose, and there are overarching classes like topical therapies that we use for patients who have limited disease. Ultraviolet light treatment takes care of the skin without affecting the internal immune system, and then [we use] systemic drugs. To a large extent, I’m relying on patient preference.

If somebody just has a couple of spots, topicals make sense. If they’re covered, then I have to do more than topicals, and there’s some middle point that is highly dependent on the patient. If they feel, “I cannot put topicals on all my spots,” then we must move on to phototherapy or systemic treatment. And you probably don’t have light boxes to offer your patients, but there may be tanning beds in your community. In theory you could even recommend light treatment to patients for their skin disease.

There are so many dimensions to consider among therapies, and 1 therapy is not better than all the others on all the dimensions. And patient preferences for different aspects of treatment may vary from my preferences, so choosing a therapy is something I have to do in collaboration with the patient.

Anthony M. Turkiewicz, MD: Absolutely. Hillary, from the rheumatology standpoint, same question. [What are your] high-level overview goals of therapy, thinking about comorbidities and prior therapies? Walk us through psoriatic arthritis.

Hillary E. Norton, MD: I like how Steve touched on the shared decision-making of the patient, because we’re talking about that a lot more in rheumatology these days. Patient preference comes into this so much. But in terms of guiding the patient when we’re talking about goals, we’re thinking about controlling inflammation and pain and preventing joint damage. We’re also thinking about treating their skin, preventing disability, and fatigue, and these other PROs [patient-reported outcomes] have historically been a cringe-inducing thing for rheumatologists because fatigue is so multifactorial. Many of our patients have depression as well.

We’re getting data from our clinical trials on our therapies, but we can improve fatigue. As John mentioned, we know that this is cytokine based; it’s part of the pathophysiology. We’re thinking about the whole picture.

And then comorbidities. You mentioned that Anthony. Many of these patients are at risk for other things, like uveitis and inflammatory bowel disease. We’re taking that into account when we’re selecting a therapy.

Our treatment is going to be guided by the domains that are involved with psoriatic arthritis. We are going to be thinking in terms of those guidelines that we have: Do they have primarily severe skin involvement? Are their joints more severe? You know, dactylitis, enthesitis. We’re going to be thinking about what is front and center for that patient when we’re choosing a therapy.

And disease severity definitely plays into it. We’re going to be looking at markers for poor prognosis and rapidly progressive disease. Many joints involve these types of things when we’re assessing severity and choosing a therapy.

Anthony M. Turkiewicz, MD: As Steve mentioned, all these entities should be shared decision-making with the patient. In this disease, it’s clearly a challenge. But there are plenty of therapies, and trying to tailor the therapies to the patients’ needs and expectations is important.

John, looking at these therapies, we have a number for psoriatic arthritis. Can you touch on the importance of optimal timing of therapeutic intervention for effectively managing the psoriatic disease? What’s important to get the patient into a clinic and onto appropriate therapy?

John Tesser, MD: It’s fair to say that most of us optimally would like to have the ability to diagnose a patient with relatively new-onset disease. The opportunities to do that are not high. Oftentimes patients are coming to us with years of disease. As a result, we’re losing out on that new window for the disease. Does it make a difference? It does, although from the trials that we’ve looked at over the years, the progression of joint damage is gold standard the ability of a disease to account for deformity and disability. For most patients, the progression of x-ray damage in psoriatic arthritis is not as rapid as it is in rheumatoid arthritis. Obviously, you always have individual patients for whom things might be different. Nonetheless, it’s fair to say that as soon as we diagnose a patient with the disease, we want to institute proper management as quickly as possible. We want to institute that therapy in such a fashion that we follow them closely to determine if the patient is responding. If they are not responding, then we advance therapy in a timely fashion.

This is a treat-to-target approach, in my mind. It’s not as fully developed and welcomed by rheumatologists for this disease as much as it is for rheumatoid arthritis, and one can even wonder about that.

The concept of starting therapy, seeing if a patient responds, and changing their therapy if they’re not is extremely important. It’s important because we want to give our patients optimism that we can get control of the disease and get them to a much better place. But if we don’t approach this in a step-wise fashion and use this optimal-timing approach, sometimes they just get fatigued at what we’re doing and stop coming and adhering.

Anthony M. Turkiewicz, MD: Understanding their expectations, this concept is getting our patients into us and into dermatology for active diagnosis as soon as possible.

Transcript Edited for Clarity

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