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Description : This medical presentation titled "Latest Developments and Expert Outlook on Management of Psoriatic arthritis" describes the etiology and socioeconomic and psychosocial burden of PsA and the importance of early detection and treatment. It also tells about classification criteria into assessment of suspected PsA cases and identifying PsA-associated comorbidities, such as CVD, obesity, and IBD, as well as their implication on the choice of treatment options.

Tags : Management, Psoriatic arthritis, etiology, socioeconomic, psychosocial burden, PsA, detection, treatment, treatment options

Published on : Apr 27, 2021 | Views : 2078 | Downloads : 4

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Faculty M. Elaine Husni, MD, MPH Vice Chair, Rheumatology Director, Arthritis and Musculoskeletal Center Cleveland Clinic Assistant Professor Cleveland Clinic Lerner College of Medicine Case Western Reserve University Cleveland, Ohio Joseph F. Merola, MD, MMSc Assistant Professor, Harvard Medical School Director, Clinical Unit for Research Innovation and Trials (CUReIT) Director, Center for Skin and Related Musculoskeletal Diseases Associate Program Director, Harvard Combined Internal Medicine-Dermatology Residency Training Program Brigham and Women’s Hospital Boston, Massachusetts
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Learning Objectives
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Learning Objectives continued
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Module 1: Prevalence and Burden of Disease; Importance of Early Screening and Classification Criteria In this module, we address the prevalence and psychosocial burden of psoriatic arthritis (PsA), as well as the ongoing clinical challenges of underdiagnosed patients suffering with PsA. We discuss the importance of early detection and will review available screening questionnaires that can help provide an earlier diagnosis.
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Prevalence and Disease Burden of Psoriatic Arthritis American Academy of Dermatology Work Group, et al. J Am Acad Dermatol. 2011;65:137-174. Gladman DD. F1000Res. 2016; 5: 2670; Eder L, et al. Int J Clin Rheumatol. 2012;7(6):641-649;
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Prevalence and Psychosocial Burden of PsA Manifestations of arthritis in majority of patients (~85%) may not emerge until several years following evidence of skin disease Peak age of onset between 30 and 55 years More than 30% of psoriasis patients will develop PsA More men present with axial disease and radiographic damage Women exhibit worse functional outcomes compared to men Psychological burden and worse quality of life [than patients with psoriasis alone] Chronic conditions of psoriasis and arthritis “affect both the skin and joints, and can result in both functional and cosmetic concerns.”—Husni, Merola, et al. 2017 American Academy of Dermatology Work Group, et al. J Am Acad Dermatol. 2011;65:137-174. Gladman DD. F1000Res. 2016; 5: 2670; Eder L, et al. Int J Clin Rheumatol. 2012;7(6):641-649; Nas K, et al. Mod Rheumatol. 2017;27:345-349; Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.
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Disease Burden of PsA Higher risk of developing PsA with presence of scalp psoriasis, nail lesions, inverse/intertriginous disease, extent of psoriasis and specific genetic markers1–3 Most patients (40–60%) suffer progressive, erosive, and potentially deforming joint disease resulting in decreased quality of life, comorbidities, disabilities, and extra-articular manifestations3,4 Economic burden of underdiagnosed and undertreated PsA: ~$35.2 billion annual healthcare burden5 $10,754 per individual (2013 prices) annual indirect costs of work disability6 1. Gladman DD. Rheum Dis Clin North Am. 2015;41(4):569-579; 2. Dolcino M, et al. PLoS One. 2015;10(6):e0128262. 3. Helliwell PS, et al. Rheum Dis Clin North Am. 2015;41(4):581-591; 4. Eder L, et al. Arthritis Rheumatol. 2016;68(4):915-923. 5. Feldman SR, et al. Arthritis Care Res. 2015;67(5):708-717. 6. Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.
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Challenges with Underdiagnosed PsA MAPP study reports average delay in diagnosis of 5 years1 Diagnosis often missed due to low level of awareness by clinical training with failure to connect skin and joint symptoms, primarily PCPs and dermatologists2 Results in progressive joint damage, deformities, disabilities, and reduced quality of life3,4 Dermatologists play pivotal role in the diagnosis of PsA Skin manifestations typically present before joint signs and symptoms5 Failure to recognize connection between skin and joint symptoms6 Mease et al—41% of PsO patients with PsA were not previously diagnosed7 Even 6-month diagnostic delay of effective treatment results in long-term poor radiographic and functional outcomes, such as bone erosion2,8 1. Kavanaugh A, et al. Rheumatol Ther. 2016;3:91-102. 2. Husni ME, et al. Semin Arthritis Rheum. 2017:351-360; 3. Philipose J, et al. Journal of Musculoskeletal Medicine (Online). 2012; 4. Helliwell P, et al. Arthritis Care Res. 2014;66:1759-1766; 5. Gottlieb AB, et al. Dermatol Clin. 2016;34:235-242. 6. van de Kerkhof PC, et al. J Eur Acad Dermatol Venereol. 2015;29:2002-2010. 7. Haroon M, et al. Ann Rheum Dis. 2015;74:1045-1050. MAPP, Multinational Assessment of Psoriasis and Psoriatic Arthritis; PsO, psoriasis
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Importance of Early Detection and Treatment
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Importance of Early Detection and Treatment Delayed and misdiagnosis results in negative impact on Overall health outcomes Quality of life Mental health Early detection can lead to improved, appropriate, timely treatment Prompt diagnosis and treatment can improve overall clinical outcomes* *Philipose J, et al. Journal of Musculoskeletal Medicine.. 2012. 3. Haroon M, et al. Ann Rheum Dis. 2015;74(6):1045-1050.
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Clinical Presentation of Psoriasis
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Psoriasis Phenotypes Merola JF, et al. Clin Exp Dermatol. 2016;41:486-9. n=3850
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Clinical Presentation of Psoriatic Arthritis Clinical presentation of PsA is complex and heterogeneous PsA manifestations may include Increased asymmetric and oligoarticular joint involvement Distal interphalangeal joint involvement Dactylitis Enthesitis Psoriatic skin lesions Nail changes, including pitting, ridging, and/or distal onycholysis Increased symptoms of stiffness, pain, fatigue, and anxiety Raychaudhuri SP, et al. J Autoimmun. 2017;76:21-37; Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.
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Clinical Presentation of PsA
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Clinical Presentation of PsA Dactylitis
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Enthesitis
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Clinical Domains of PsA Peripheral arthritis Affects large joints Axial disease Chronic inflammatory arthritis, involving spine and or sacroiliac joints Varies among 25% to 70% of patients with PsA Enthesitis Dactylitis Inflammation of an entire digit Skin Nail disease Comorbidities Coates LC, et al. Arthritis Rheumatol. 2016;68:1060-71; Ritchlin CT, et al. Ann Rheum Dis. 2009;68:1387-1394; Gladman DD. Rheum Dis Clin North Am. 2015;41:569-579.
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Diagnostic Work-Up Currently no standardized diagnostic test for PsA: clinical diagnosis Diagnostic work-up for PsA is based on: Medical history Physical examination Blood tests Imaging Review measurable elements to assess disease severity Number of joints affected or amount of swelling Ritchlin CT, et al. Ann Rheum Dis. 2009;68:1387-1394; Eder L, et al. Int J Clin Rheumatol. 2012;7:641-649.
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CASPAR: Classification Criteria for PsA Requires presence of inflammatory arthritis (e.g., joint, spine, or enthesis) for accurate diagnosis Criteria highly specific (99%) for PsA Personal history of psoriasis (current or past) Family history of psoriasis Psoriatic nail dystrophy Negative rheumatoid factor test Dactylitis Radiographic evidence of juxta-articular bone formation Husni ME, et al. Semin Arthritis Rheum. 2017:351-360; Raychaudhuri SP, et al. J Autoimmun. 2017;76:21-37; Coates LC, et al. Arthritis & Rheumatism. 2012;64:3150-3155; Philipose J, et al. Rheumatologynetwork.com. 2012. CASPAR, ClASsification criteria for Psoriatic ARthritis
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Raychaudhuri SP, et al. J Autoimmun. 2017;76:21-37; Karreman MC, et al. Rheumatology. 2017;56:597-602; Mease PJ. Drugs. 2014; doi 10.1007/s40265-014-0191-y; Ogdie A, et al. Rheumatic diseases clinics of North America. 2015;41:545-568
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Activity Measures for PsA Disease Activity Assessment and Composite measures for PsA* MDA: Minimal disease activity CPDAI: Composite Psoriatic Disease Activity Index First composite measure of disease activity DAPSA: Disease Activity in Psoriatic Arthritis score PASDAS: PsA Disease Activity Score Reliable and holistic composite index to measure disease activity RAPID3: Routine Assessment of Patient Index Data 3 *Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.
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Minimal Disease Activity Minimal disease activity (MDA) 5 out of 7 of the following: TJC 1 SJC 1 PASI 1 or BSA 3% Patient pain VAS 15 Patient global activity VAS 20 HAQ 0.5 Tender entheseal points 1 Coates LC, et al. Ann Rheum Dis. 2010;69:48-53. TJC, tender joint count; SJC, swollen joint count; PASI: Psoriasis Area and Severity Index; BSA, body surface area; VAS: visual analog scale; HAQ: Health Assessment Questionnaire
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Module 2: Comorbidities In this module, we will discuss common comorbidities and risk factors associated with psoriatic arthritis and implications to disease management.
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Addressing Co-Morbidities Increased prevalence and incidence of CVD, diabetes, obesity, depression, and anxiety in patients with active PsA Comorbidities 50% of patients with PsA have at least 1 comorbidity Results in decreased quality of life Implications to disease management Review patient satisfaction with current treatment options Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.
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Comorbidities associated with PsA Patients with PsA have more comorbidities than the general population Greater risk for IBD in patients with psoriasis and PsA Higher risk for cardiovascular disease1, 2 Leading cause of death (20-56%) in patients with PsA1 Identify high-risk CVD patients who may need more aggressive intervention Higher risk for depression (than patients with psoriasis alone) Presence of comorbid depression may affect adherence to treatment 1. Husni ME, et al. Semin Arthritis Rheum. 2017:351-360; 2. Craven J. RheumatologyAdvisor.com. 2017. IBD, inflammatory bowel diseases; CVD, cardiovascular disease
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Husni ME, et al. Semin Arthritis Rheum. 2017:351-360; Husni ME. Rheum Dis Clin North Am. 2015;41(4):677-698.
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Why Are Comorbidities Important to Recognize? Allows comprehensive evaluation and management of the patient, and manifestations of disease May affect choice of therapeutic agents CAD Risk benefit of anti-osteoblastic activity of NSAIDs need to be balanced by risk of CAD, exacerbation of HTN Goodson et al—Use of NSAIDs associated with reduced CV mortality (Trelle et al—doubling of risk of CVD with NSAIDs in general population) IBD May be exacerbated by NSAIDs (Sandborn WJ et al—not Celecoxib?) Not all anti TNFs efficacious or approved for IBD Uveitis: Monoclonal anti TNF > Receptor antagonists Sulfasalazine may have a role Goodson N, et al. Ann Rheum Dis. 2009;68: 367–372; Trelle S, et al. BMJ. 2011; 342: c7086. CAD, coronary artery disease; CVD, cardiovascular disease; HTN, hypertension; IBD, inflammatory bowel disease; TNF, tumour necrosis factor
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Cardiovascular Morbidity in PsA 3 large studies confirmed an increased CV morbidity in PsA, including: IHD, CHF, CVA, and PVD Varying study designs and differences in CV endpoints Broadly comparable with other chronic diseases, such as diabetes and RA PsA has an increase in death rate of 1.3 due to CVD compared with general population Ahlehoff O, et al. J Intern Med. 2011;270:147-57; Gladman DD, et al. Ann Rheum Dis. 2009;68:1131-5; Han C, et al. J Rheumatol. 2006;33:2167-72; Wong K, et al. Arthritis Rheum. 1997;40:1868-72. IHD, ischaemic heart disease; CHF, Congestive heart failure; CVA, cerebro-vascular accident; PVD, peripheral vascular disease
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Fatty Liver Disease NAFLD was significantly associated with metabolic syndrome, obesity, and dyslipidemia Patients with PsA were more likely to have NAFLD than patients with Psoriasis but without PsA (OR 3.94; 95%CI: 1.07-14.46) Di Minno MN, et al. Arthritis Res Ther. 2012;14:R211. HS, hepatic steatosis; MDA, minimum disease activity; NAFLD, non-alcoholic fatty liver disease Hepatic steatosis affects the likelihood of not achieving MDA: aHR 1.91 (1.04-3.38)
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Screening Considerations Ogdie A, et al. Curr Opin Rheumatol. 2015;27:118-26. ROS, review of symptoms; LFTs, liver function test; Cr, creatinine; HBV/HCV, hepatitis C virus/hepatitis C virus
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GRAPPA Considerations for Treatment of Patients With PsA and Concomitant Comorbidities Coates LC, et al. GRAPPA 2015 Treatment Recommendations for Psoriatic Arthritis. Arthritis Rheumatol. 2016;68:1060-71. *When treating patients with chronic infections that can affect the liver, consider consultation with providers having expertise in the area. † Corticosteroids used as preferred therapy for uveitis are most commonly given as topical and/or intraocular injections (IAIs) in preference to oral steroids. GRAPPA, Group for Research and Assessment of Psoriasis and Psoriatic Arthritis; NSAIDs, nonsteroidal anti-inflammatory drug;. HCQ, hydroxychloroquine; CV, cardiovascular disease; HIV, human immunodeficiency virus. Anti-IL17 CC?
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Module 3: Provider Interdisciplinary and Clinician-Patient Communication In this module, we emphasize the importance of interdisciplinary communication. We will discuss how to develop care models through clinician communication, a patient-centered approach to treatment strategy, as well as the significance of clinician-patient communication addressing adherence.
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Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.
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PPACMAN A non-profit organization The mission of PPACMAN is to nucleate PsO/PsA combined clinics and centers to advance a multilevel approach to psoriatic patients, increase disease awareness and accelerate management Develop networks and relationships between community-based centers: create local-regional derm-rheum and other clinical partnerships Provide toolkits for starting combined partnerships, EMR templates, screening efforts, etc. Research agenda www.ppacman.org Okhovat JP, et al. J Rheumatol. 2017;44:693-694; Velez NF, et al. Arch Dermatol Res. 2012;304:7-13. EMR, electronic medical records “Patients seen during a combined clinic had their diagnosis revised in 46% of the cases and were more likely to be treated with an appropriate systemic therapy than before (25% vs 15% and 37% vs. 16%, respectively)”. —Velez NF et al. Arch Derm Res. 2012; 304(1):7-13. Psoriasis & Psoriatic Arthritis Clinics Multicenter Advancement Network
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The Power of Co-Management and Communication How to communicate with other providers Establish roles Improve communication between PCP and rheum, and when appropriate, dermatologist, and psychiatrist Referral to rheumatologist Referral to psychologist trained in pain, when appropriate Read each others’ notes Pick up phone to discuss co-management Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.
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Co-Management in Practice Shared decision making and treatment objectives improve outcomes Monitor treatment (across the disciplines) Communicate to help improve patient adherence to treatment Collaborative care essential to address needs of PsA patient Help to avoid rebound risk and non-adherence to therapy Utilize physician assistants and specialist nurse practitioners Ritchlin CT, et al. Ann Rheum Dis. 2009;68:1387-1394; Garrido-Cumbrera M, et al. Rheumatol Ther. 2017; 4:219–231.
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Module 4: Therapeutic Management Patient-Centered Approach to Treatment In this module, we will focus on mechanism of action of approved biologic treatment options, as well as the latest safety and efficacy data. We will provide insights into improving patient adherence.
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Updated Guideline Recommendations 2016 EULAR guideline updates Based on new pharmacological agents (approved since 2009) IL-17i IL-12/23i PDE-4i TNFi Focus on musculoskeletal manifestations See EULAR algorithm for sequential treatment strategies to optimize outcomes* *Gossec L, et al. Ann Rheum Dis. 2016;75(3):499-510. EULAR, European League against Rheumatic Diseases; PDE-4i, phosphodiesterase 4; TNFi, tumor necrosis factor-alpha inhibitors inhibitor
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GRAPPA Recommendations Select therapy based on most severe element of patient’s disease1,2 Focus on achieving low disease activity for disease domains of PsA Optimize functional status Minimize complications Improve quality of life [Rheumatologists] Take a more active role educating PCPs Screen for comorbidities, including obesity, anxiety, depression, and skin cancer3 Monitor and adjust treatment regularly 1. Coates LC, et al. Arthritis Rheumatol. 2016;68(5):1060-1071; 2. Pappas S. 2016. 3. McKnight W. Updated GRAPPA PsA recommendations. 2016. GRAPPA, Group for Research and Assessment of Psoriasis and Psoriatic Arthritis
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Patient-Centered Approach to Treatment Strategy Consider the whole patient, including skin, joints, and known comorbidities, as well as psycho-social issues Importance of patient involvement in decision-making T2T recs based on shared decision making [between patient and specialist] Clinicians should convey details of treatment options and side effects Provide clinician-to-patient education on the following: Etiology Trigger factors Treatment options and side effects Garrido-Cumbrera M, et al. Rheumatol Ther. 2017; 4(2): 219–231. T2T, treat to target
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Established Treatment Options Early stages are often treated with established agents NSAIDs—often first-line treatment Corticosteroids Oral csDMARDs—often second-line treatment (e.g., sulfasalazine, leflunomide, hydroxychloroquine) Dependent on the following patient-related factors Disease domain Prognostic factors Associated comorbidities Switch to a TNFi or novel biologic agent is often warranted Severity of disease Patient’s treatment preference based on side effects, administration, frequency Coates LC, et al. Arthritis Rheumatol. 2016;68(5):1060-1071; Gossec L, et al. Ann Rheum Dis. 2016;75(3):499-510; Husni ME, et al. Semin Arthritis Rheum. 2017:351-360. NSAIDs, nonsteroidal anti-inflammatory drugs; csDMARDs, conventional synthetic and targeted synthetic DMARDs; TNFi, tumor necrosis factor inhibitor
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Current Evidence-Based Treatment Strategies Continued understanding immunopathogenesis of PsA led to development of novel agents Biologics block the action of cells and proteins that play a major role in developing psoriasis and psoriatic arthritis Administration route by subcutaneous injection or by IV infusion National Psoriasis Foundation. Moderate to Severe Psoriasis and Psoriatic Arthritis: Biologic Drugs. Available at https://www.psoriasis.org/about-psoriasis/treatments/biologics. TNF-alpha, tumor necrosis factor-alpha
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1. Kavanaugh A, et Ann Rheum Dis. 2014;73:1689-94; 2. Mease PJ, et al. Ann Rheum Dis. 2017;76:79-87; 3. Mease PJ, et al. Rheumatol Ther. 2016;3:5-29; 4. Mease P, et al. Ann Rheum Dis. 2018. pii: annrheumdis-2017-212687; 5. Nash P, et al. Arthritis Res Ther. 2018;20:47. TNFi-alpha, tumor necrosis factor-alpha inhibitor; QoL, quality of life
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1. Roberts J, et al. Immunotherapy. 2018;10:361-372. 2. Kavanaugh A, et al. Ann Rheum Dis. 2014;73(6):1000-1006; 3. Araujo EG, et al. Arthritis Rheumatol. 2017; 69 (suppl 10); Mease PJ, et al. Arthritis Rheumatol. 2017; 69 (suppl 10); 5. Elyoussfi S, et al. Rheumatol Int. 2016;36:603-612. 6. Ritchlin CT, et al. Curr Opin Rheumatol. 2016;28:204-210; 7. vanaugh A, et al. Ann Rheum Dis. 2014;73:1020-1026; 8.. Nash P, et al. Ann Rheum Dis. 2018. pii: annrheumdis-2017-211568. 9. Henriques C. Psoriasis News Today. 2016. 10. Mease PJ, et al. Ann Rheum Dis. 2017;76:1550-1558. cAMP, Cyclic adenosine monophosphate; JAK, Janus kinase inhibitors; QoL, quality of life
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Efficacy and Safety of Approved Biologics Common adverse events for biologic agents: Nasopharyngitis, headache, upper respiratory tract infection, and arthralgia Slight increase in rate of serious infection TNFi efficacy reported to be higher among patients with normal body weight compared to those who are overweight* Encourage patients to achieve and maintain a healthy bodyweight to achieve minimal disease activity IL-17 inhibitors do not seem to protect against flares of inflammatory bowel disease, a known risk in patients with PsA *Eder L, et al. Ann Rheum Dis. 2015;74(5):813-817. TNFi, tumor necrosis factor-alpha inhibitors; IL-17, Interleukin 17
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Optimal Treatment Selection Determine optimal treatment selection based on: Long-term safety data of biologics Contraindications Tolerability Efficacy Costs (biologics) Assess clinical severity Strategy of treatment order Treat to Target in psoriatic arthritis: Tight Control of PsA (TICOPA) study Initiate or maintain systemic therapy
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Improving Patient Adherence MAPP survey results of patients with PsA1,2: 45% discontinued oral or biologic therapy due to issues with safety, tolerability, or a lack of efficacy 64% concerned about health risks with long-term therapy 90% expressed need for better therapies Improve clinician/patient communication Develop treatment plan3,4 Simple Iterative Incorporates patient’s comorbidities 1. Kavanaugh A, et al. Rheumatol Ther. 2016;3:91-102; 2. Lebwohl M, et al. J Am Acad Dermatol. 2014;70:871-881; 3. Coates LC, et al. Arthritis Rheumatol. 2016;68:1060-1071; 4. Pappas S. 2016. http://www.rheumatologynetwork.com/psoriatic-arthritis/psa-treatment-guidelines-organized-five-domains. MAPP, Multinational Assessment of Psoriasis and Psoriatic Arthritis
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Patient-Reported Outcomes (PRO) RAPID3: Routine assessment of patient index data Patient-reported, composite index designed for feasibility in clinical care Core data set patient self-reported measures Physical function Pain Patient global estimate PsAID: Psoriatic Arthritis Impact of Disease questionnaire Two PsAID questionnaires developed with physical and psychological domains: Clinical practice (12 domains of health) Articular disease activity, severity of psoriasis, and presence of a coexisting fibromyalgia Clinical trials (9 domains) DLQI: Dermatology Life Quality Index—measures impact of dermatological disease Husni ME, et al. Semin Arthritis Rheum. 2017:351-360; Gossec L, et al. Ann Rheum Dis. 2014;73:1012-9; Coates LC, et al. Arthritis Care Res. 2017. PsA, psoriatic arthritis; RA, rheumatoid arthritis
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Domains Most Impacted by PsA Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.
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Module 5: Therapeutic Management (Treat to Target) In this module, we review treatment objectives, including treat-to-target strategy and treatment management, which includes continued assessment of musculoskeletal disease, skin disease, and health‐related quality of life. We also share highlights from upcoming 2018 ACR guidelines, and review the latest data from emerging treatments. Coates LC, et al. Arthritis Rheumatol. 2018;70(3):345-355.
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National Psoriasis Foundation Treat-to-Target: SKIN NPF T2T in psoriasis = Target response BSA ≤1% @ 3 months and q6 months (or “acceptable response” of BSA ≤3% at 3 months or 75% improvement from baseline) NPF, National Psoriasis Foundation; T2T, treat-to-target; BSA, body surface area
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Minimal Disease Activity Minimal disease activity (MDA) 5 out of 7 of the following: TJC 1 SJC 1 PASI 1 or BSA 3% Patient pain VAS 15 Patient global activity VAS 20 HAQ 0.5 Tender entheseal points 1 Coates LC, et al. Ann Rheum Dis. 2010;69:48-53. TJC, tender joint count; SJC, swollen joint count; PASI: Psoriasis Area and Severity Index; BSA, body surface area; VAS: visual analog scale; HAQ: Health Assessment Questionnaire
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DPSA Remission Criteria DAPSA: Disease Activity and Psoriatic Arthritis Score Validated treatment target in daily practice <4 is remission cutoff PASDAS, remission cutoff <1.9
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Treatment Objective Treat-to-target strategy to optimize patient care Use quantitative measures (e.g., PASDAS) of disease activity to maximize achieving very low-disease activity or remission An integrated approach to therapeutic intervention Remission The absence of clinical and laboratory evidence of significant inflammation or minimal-disease activity Coates L, et al. Ann Rheum Diseases. 2017;76:948-949. PASDAS, The Psoriatic Arthritis Disease Activity Score
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Treatment Algorithms and Switching Tailor treatment for individual patients, taking into account… Disease activity and severity Prognostic factors Comorbidities Cardio-metabolic risk factors Treatment history Access to therapies Repeated evaluations Patient preference Incorporate assessment and management of psychological and physical concerns of patients Gossec L, et al. Ann Rheum Dis. 2016;75(3):499-510; Merola JF, et al. Semin Arthritis Rheum. 2017;47:29-37. Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.
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Take Aways for PsA Early diagnosis and early, aggressive treatment should aim to halt or minimize joint damage and clearing skin psoriasis Treat key clinical domains (i.e., arthritis, spondylitis, enthesitis, dactylitis, skin, and nail disease) Be aware of comorbidities and their implication to treatment approaches Collaborate with an interdisciplinary approach to screening and managing patients Apply treat-to-target strategies to improve patient outcomes Educate patients on range of available treatments and new options Help patients gain a better understanding of their condition and how to manage it Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.