Anthony M. Turkiewicz, MD: Tagging along with that, quality of life [QOL] issues. Obviously, the burden of disease is quite prevalent. Can you give some insight into that, and some tools that are used to measure quality of life, maybe some PROs, patient reported outcomes, maybe used more in clinical trials, or things they use in the clinic?
Hillary E. Norton, MD: Psoriatic arthritis [PsA] affects quality of life in so many different areas. This affects physical health, mental health, ability to do activities of daily living, and just general well-being. There are tools that we use in the clinic. We don’t have as many measurement tools that we use on a consistent basis as we do in rheumatoid arthritis. In the clinic most people are going to be looking at a patient global [assessment] or a pain score. We’ll let Dr Feldman talk about if we’re measuring the skin in the clinic, then there are different instruments that are used for that. But when we’re looking at psoriatic arthritis as a whole, it’s generally going to be the patient global [assessment].
Now when we’re doing clinical trials, of course we’re measuring quality of life using things like the HAQ-DI [Health Assessment Questionnaire Disability Index], using FACIT-Fatigue [Functional Assessment of Chronic Illness Therapy-Fatigue], and these are really helpful when we’re interpreting clinical trial data.
Anthony M. Turkiewicz, MD: That’s very helpful.
John Tesser, MD: Anthony, if I could add one thing because Hillary laid it out really well. But I do think it’s important, and I believe Steve would agree with this, that from a patient’s perspective…as rheumatologists we focus on their joints and we acknowledge their skin. Maybe for dermatologists, at least some of them, it might be the other way around. But from the patient’s perspective, they have both. Both of those issues affect their QOL. And we may think that, well if they have a lot of [issues with] skin and not too much with joints, that’s more important than the other way around.
But I don’t think it’s always that way. It’s both of those issues affect their quality of life. And there have been some data generated to reflect that, and it does come into play when we take a look at some of the trials that we’ll talk about later.
Anthony M. Turkiewicz, MD: Absolutely. Clearly numerous issues can play a role in what’s important to the patient. It’s important as health care practitioners that we recognize what’s truly affecting the quality of life, and that’s an excellent point, John.
John, I’ll go ahead and ask you since you so eloquently laid out the pathophysiology and alluded to this. We think about having comorbidities that would be associated with psoriatic arthritis. And related to that in some way would be, let’s say, the domains that the research group GRAPPA [Group for Research and Assessment of Psoriasis and Psoriatic Arthritis] has outlined for us through the years in PsA. Do you want to discuss the GRAPPA domains, and also perhaps fill in the comorbidities that we associate with PsA?
John Tesser, MD: Let’s start with the comorbidities. We can start from the head and go down. There’s depression and significant fatigue that’s associated with the disease, reflecting central nervous system issues. There can be uveitis and iritis, conjunctivitis, and what have you. We certainly see psoriasis. The systemic effects on the cardiovascular system are immense. We’ve been discovering later than we did for rheumatoid arthritis how important these issues are for increasing the risk of MI [myocardial infarction], CVA [cerebrovascular accident], and heart failure, and arterial disease in general throughout the system with the metabolic effects in terms of there being the development of diabetes and the associated metabolic issues that are related to that. Then, of course, we have osteoporosis, and the arthritis, and the issues of colitis.
The burden of disease systemically is immense. And as I tend to think of it and tell people: Don’t think of it as psoriatic arthritis causing these manifestations. These manifestations and the arthritis and the psoriasis, they are the disease, the depression is the disease. And there is basic research that demonstrates how cytokines, for example, are inherently involved in depression and fatigue.
Those are the comorbidities. The GRAPPA domains are interesting, and they focus on the musculoskeletal and skin issues of the disease. They have been developed by GRAPPA, and they act as a guide in terms of identifying which areas of a given patient you want to understand are diseased, and how much disease, and then that might guide your therapy. But the domains themselves are things that I’ve already brought out with a couple of others.
We have arthritis; we have enthesitis; there’s dactylitis, which is the completely swollen digit, either toe or finger. Underlying that is the fact that the tendons, the full ray of the limb, are affected by the disease, and inflammation throughout the tendonosis and ligamentous structures allow for the sausage toe or sausage finger.
Then there’s nail disease, which is an extension of the tendon inflammation, because the tendons’ extension into the nail bed, it basically forms the nail bed. As a result it’s completely understandable why there would be nail disease in this disease, and Steve can certainly comment on that more fully.
We have all of these different domains, and the skin, of course I don’t want to leave out the skin. If you line them up in a row and you look at the GRAPPA guidelines in terms of the treatment of the disease, that allows for us, in a structured way, to understand how one can sort through which areas to treat and how different treatments may be chosen on the basis of what we know is effective.
Anthony M. Turkiewicz, MD: Steve,can you comment on that, particularly for the nail involvement? In PsA it’s mostly GRAPPA domains, but there is dermatology input as well; are the GRAPPA domains utilized or recognized by the dermatology community?
Steven R. Feldman, MD, PhD: No. The GRAPPA domains would be thought of, at least within the world of dermatology, as something people might think about for their clinical trials and not so much for their clinical practice. In clinical practice dermatologists look at much more subjective assessments of their patients and treat accordingly.
Transcript Edited for Clarity