Treating Treatment-Resistance PsA


Experts consider optimal treatment strategies for patients with treatment-resistant psoriatic arthritis.


Michele M. Cerra, MSN, FNP-C: Let's talk about how aggressive we want to be in our approach with patients we start on therapy, and despite being on therapy, they still have active psoriatic arthritis. We know [the disease] is so complex and that some of these patients just have many comorbid conditions with it: theyhave axial disease and peripheral disease and skin disease all in one. How aggressive are you with your treatment so [that treatment] doesn'taffect the patient's quality of life?

Nancy Eisenberger, MSN, FNP-C: I'm extremely aggressive. I don't accept any inflammation because inflammation causes other comorbidities as well. Again, treating a whole patient as you do, I make sure that if my patient is on a biologic and they're not doing well enough, sometimes I'll add an oral DMARD (disease-modifying anti-rheumatic drug). We have small molecule inhibitors like apremilast that we can use in conjunction with the biologics at this point. That does a good job on the skin if the patient can tolerate it as well as helping joint pain and some of the [other] symptoms. I make sure I treat my patients to remission. As long as a patient is willing to take medication, I will go as far as I can keeping them safe and getting them to have as few symptoms as possible.

Michele M. Cerra, MSN, FNP-C:Just like here in my practice, I use monotherapy if I can get by. Despite treating patients with a biologic on monotherapy, combination therapy with small molecule, triple therapy, even adding in that methotrexate or that otherDMARD, I will wait and see if a DMARD or a biologic is working. Weused to betaught to wait; you wait about 6 months for treatment. But we know that with the moderate to severe disease, we're risking joint damage and disability from psoriatic arthritis. Now I'm waiting about 3 months to switch therapy or add on therapy. What are you using in your practice as a guide for that?

Nancy Eisenberger, MSN, FNP-C:I do the same thing. As soon as I see my patient, I see them back in 6 weeks, just to see. Not, I don't expect full efficacy at that point, but I want to make sure they're having some improvement in their quality of life. I won't change a medication until at least 3 months of therapy. If they get no response I change it, but otherwise, I titrate up. If I have them on an oral DMARD I can titrate it up. If I have them on a biologic, I just evaluate as long as we're making some progress. After 3 months, if they're not doing well on a biologic, I will change them.

Michele M. Cerra, MSN, FNP-C: In my patients with moderate to severe psoriatic arthritis I like to do imaging, of course, as a baseline, but I like to check imaging about once a year because sometimes patients forget what their baseline was and how they used to feel before they were diagnosed with this disease. In case there’s smoldering inflammation going on in the joints or in the spine, I like to image patients about once a year. What are your thoughts on that, or what is your practice protocol?

Nancy Eisenberger, MSN, FNP-C:We don't have a practice protocol, but I agree with you….If somebody's very young, sometimes I will not do it as frequently as long as they're not complaining of symptoms. But I do certain things, especially with my older patients, to try to keep them in good control. I'll get baseline, hand, whatever their major joints are. Hands, feet, their sacroiliac joints, their cervical spine. These are areas that are affected, and I do image them periodically. If they're having a lot of hand or foot disease, I will do that on a yearly basis.

Transcript edited for clarity.

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