Spondyloarthritis - Episode 6
Philip J. Mease, MD, and John D. Reveille, MD, outline the unmet needs and educational gaps in spondyloarthritis, including collaboration, under-diagnosis, and recognizing signs and symptoms.
Philip J. Mease, MD: There are a number of educational gaps regarding psoriatic arthritis (PsA). One key one is the need to educate dermatologists—and some of the best people that do that are rheumatologists who work directly with dermatologists—to keep reminding them to be asking about symptoms of PsA and their psoriasis population. And then establish an easy conduit for referral of the dermatologist to the rheumatologist, and then having a back-and-forth so the patient goes back and forth between the two disciplines. So, it’s a very important collaboration.
Another gap is the fact that we now are increasingly understanding that there are important comorbidities and associated conditions with psoriatic arthritis. For example, the metabolic syndrome is very common in people with psoriasis and PsA. There’s a genetic predisposition to this in PsA. So, patients tend to be overweight, have hypertension, and have hypercholesterolemia, which increases their cardiovascular risk along with the inflammation of the disease. And so managing the cardiovascular aspects of the patient are very important in addition to trying to bring the disease into remission to reduce downstream problems of heart attack and stroke.
We also know that there are associated conditions like uveitis and inflammatory bowel disease, which need to be recognized and potentially managed. So, understanding the whole patient, as opposed to just focusing on the joints, is very important. And, again, that collaboration with the dermatologist is important.
Despite all of the comments that I’ve been making, we understand the disease remains underdiagnosed in the population. And so it’s important to not only educate clinicians, but also important to educate patients—and patients with psoriasis in particular—to make them aware that the arthritis symptoms that they’re experiencing may be related to psoriatic arthritis rather than run-of-the-mill degenerative arthritis.
John D. Reveille, MD: It’s an unmet need for the simple reason that if we look at some of the big insurance databases, only about 14% of people with chronic back pain ever see a rheumatologist. And so we have 86% of people with chronic back pain of whom one-third have inflammatory back pain, of whom one-quarter of that one-third will have axial spondyloarthritis, who are never getting a diagnosis because the awareness of axial spondyloarthritis as a discreet entity really isn’t very good among primary care practitioners. Yet, axial spondyloarthritis responds very well to these treatments we’re talking about today. And given that low back pain is one of the leading causes of disability and a huge contributor to the overall disease burden in this country because of the indirect costs of lost wages, lost work, disability payments, and the like, it really remains something that has to be addressed.
If we talk to community rheumatologists, again, it’s awareness, having index of suspicion. B27 testing is appropriate and can be helpful in diagnosis in the patient coming to you with inflammatory back pain; it should be something that is thought about early on. And MRI can also assist in early diagnosis, provided that you have the right collection of clinical features. And it’s ultimately the drugs we’ve talked about—nonsteroidals, biologic agents—that work best earlier in the disease course. And if you keep that in mind, keep in mind that TNF agents—by large observational trials—have been shown to actually alter radiographic progression and contrast some of the earlier work that was done with shorter-run studies.
For community physicians, I think the key thing to know is that this entity does exist, that it affects up to 1.5% of their patients, if not more, and that early diagnosis can make a big difference in what ultimately happens to the patient prognostically. Because we know that early intervention with biologic agents, or even with nonsteroidals, can help to prevent the disability and deformity that is associated with this disease. The fact of the matter is that up to 50% of patients with ankylosing spondylitis—and I’m switching back and forth, so I’m talking about the most severe form of axial spondyloarthritis, ankylosing spondylitis—are perfectly well controlled on nonsteroidal anti-inflammatory drugs (NSAIDs) alone, taking in full anti-inflammatory doses, 50%. Fifty percent don’t need these very expensive treatments that have significant side-effect profiles. And with early diagnosis, even with getting full doses of NSAIDs aboard, it can make a big difference in what ultimately happens to the patient.
The best way that doctors can educate their patients about the disease is to, number one, make them aware that the entity does exist. Number two, try to clear up any misconceptions they may have about the disease, to assure them that effective treatments are available, to get them involved in a physical therapy program earlier in the disease course rather than later—again, it works better earlier—and then to start treatment. Treatment usually starts with nonsteroidal anti-inflammatory agents given in a full anti-inflammatory dose. That’s for a person with active disease. And if they have significant peripheral joint involvement and don’t get significant benefit from the nonsteroidals alone, they might add a disease-modifying anti-rheumatic drug, such as sulfasalazine. A lot in this country use methotrexate. There aren’t good data to show that methotrexate is very effective in this setting, but it is commonly used. And finally, for the person who after 3 months of two different NSAIDs has not had an adequate response of their inflammatory back pain, to the nonsteroidal, a biologic agent should be considered.