An overview of treatment strategies and multimodality care essential to the management of psoriatic arthritis.
Michele M. Cerra, MSN, FNP-C:I like how you mention partnering with the dermatologist. It’s important for me when I'm partnering with dermatology that patients are not going to dermatology and getting switched on their medications that we start them on,because we know that the biologics and the DMARDs (disease-modifying anti-rheumatic drugs] are interchangeable, [and] some of them [are] for psoriasis and psoriatic arthritis. We know about 85% of our patients with psoriatic arthritis have skin disease: psoriasis. My approach to managing patients with psoriatic arthritis is holistic. I treat the emotional aspects of the disease—the anxiety, the depression, the sleep disturbance—and if they can't afford to be going to all these specialists and primary care, I'm managing and treating their depression. I'm helping them get some sleep. Referring them to PTOT (physical therapy & occupational therapy). If they can't afford their copay, it's encouraging them to maybe do some mild stretching, some yoga, some Pilates—just getting them to exercise their joints to prevent that long-term disability. Again, educating as you said; partnering with our other specialists.
What factors do you consider in your practice when you're prescribing or going to treat psoriatic arthritis? This is with or without psoriasis. How do you manage that and decide what treatment is best for that patient?
Nancy Eisenberger, MSN, FNP-C:There are a lot of things I consider: the age of the patient, the sex of the patient. I know that methotrexate doesn't have to be the first line of therapy. We can start straight with some of the biologics. However, cost is a factor, and sometimes the diagnosis is on the fence, where we could start with methotrexate as long as it's not a female who is of childbearing. Also, looking at the severity of their disease, if they have lots of skin and joint and tendon enthesitis and dactylitis going on, then I'm going to be more aggressive and go straight to the biologic and discuss the importance of that with the patient. Cost…is a huge thing, although most patients with insurance can get the biologics reasonably with patient assistance programs, which are something that helps the patients. Again, forward thinking about sulfasalazine, which can be used sometime as an oral DMARD, but we must worry about decreased sperm counts in men and things like that, so there are a lot of different things between teratogenic effects of medications and other adverse effects. I choose the medication for the patient, and like I said, we have such a great variety of treatments now, which we hadn't had in the past. Ten years ago, we were nowhere in the shape that we're in now where we have options for our patients.
Michele M. Cerra, MSN, FNP-C:It is important when we're looking at fertility for men and women [and] prescribing meds that we’re also looking at their comorbid conditions. If they have fatty liver disease, that stops us from using methotrexate, which we know is metabolized by the liver and can cause liver fibrosis. Also, our patients who like to enjoy a glass of wine, or until they have seen us, alcohol, to help deal with that pain that goes along with the disease state. Or due to their cardiovascular condition, we can't use certain biologics. Psoriatic arthritis is one of my favorite things to treat and see, especially because patients are frequently misdiagnosed, and you can improve the patient's quality of life when you use that holistic approach and you get them on the correct treatment.
Transcript edited for clarity.