Treatment Options for Psoriatic Arthritis
From the Show: Memorial Ohio - Memorial Health Radio
Summary:
Air Date: 3/5/19
Duration: 10 Minutes
Dr. John David Krant discusses psoriatic arthritis. He explains the symptoms you would notice, the risk factors involved, as well as the latest treatment options available at Memorial Health System.
Transcription:
Melanie Cole (Host): People who have psoriasis can also develop a condition called psoriatic arthritis which can cause pain, stiffness, and swelling in and around the joints. My guest today, is Dr. Jonathan Krant. He’s the Medical Director in the Department of Rheumatology at Memorial Health System. Dr. Krant, tell us about psoriatic arthritis. We’re hearing about it in the media, seeing commercials about it. Is this a new condition? Has it been around a while? Or are we just now learning about it?
Jonathan David Krant, MD, FACP (Guest): Well psoriatic arthritis is an extraordinarily interesting topic and it has achieved a lot of local interest especially when you have folks like Cyndi Lauper talking about Cosentyx and Phil Mickelson about Humira and Enbrel. We have a lot of celebrities who are bringing this disease state to our awareness and of course, it’s been around forever. We have just not been that good at recognizing it.
When we look at the domain of psoriasis and psoriatic arthritis it seems that about 30% of folks who have got guttate psoriasis which is the usual psoriatic plaque that one sees on the scalp, elbows, knees, about 30% of folks with psoriasis vulgaris or guttate disease will go on to develop arthritis. And the arthritis is typically a small joint in the distal interphalangeal joints of the fingers, the guys who have your nailbeds on them, in addition to a large weightbearing joint, usually a knee, an ankle. It’s very different from rheumatoid arthritis. It’s not a symmetric small joint process. It’s a generalized large joint arthritis often, but not always seen in the setting of psoriasis.
The things that make this particularly of interest are that a lot of the features of psoriatic arthritis occur outside the joint. You could have a hot, swollen digit, a condition called dactylitis. You can have insertional pain of the Achilles where the Achilles tendon inserts into bone, that’s called enthesitis. There are other spots, spots as well. The elbows, the knees. It’s a remarkable phenomenon and when you couple that with tenderness over the sacroiliac joints, sacroiliitis and a hot inflammatory eye, uveitis; you have got this broad spectrum of disease activity. Negative rheumatoid factor, nailbed involvement with pitting and ridge formation, separation from the nailbed, the nails that is, plus psoriasis, plus these interesting features dactylitis, enthesitis. Have I intrigued you yet? If not, I’ll keep going.
Host: You absolutely have and it’s fascinating and as you say, there’s Cyndi Lauper and we see all these commercials. Who would spot this Dr. Krant? Would that be you go to your dermatologist, you’ve got some issues with your nailbeds or your skin or you see your primary care provider because you’re in pain or even your orthopod because you’ve got Achilles problems? Who diagnoses this?
Dr. Krant: So, that’s a great question. For years I’ve been advocating a partnership between pharmacy - with the pharmaceutical industry and clinicians to develop a community disease awareness ambassador program. These are folks who would be hairdressers or folks working in nail salons who are educated with a very simple slide deck to recognize folks who have pitting of nailbeds, psoriasis of the scalp and are referred on very, very quickly to rheumatology directly. Unfortunately, we are not there yet. We are flushing out some initiatives along those lines, but the usual suspects are the primary care physicians, nurses, nurse practitioners, PAs. The front line folks will see the psoriasis, hear the complaints about joints and say go take some aspirin or some Advil and we will see you in the morning.
Typically, though, things don’t get better, they progress and one of the features that we are aware of is untreated, this disease will form deforming arthritis as well as cause major organ involvement in some cases, all of which can be obviated if we are early disease awareness ambassadors, that is everyone of us. If you have a relative with psoriatic skin who is complaining of joint pain, bring it to your physician’s attention. If your physician is giving you anti-inflammatories, but not thinking about biologic therapies drugs like Cosentyx or Humira or Enbrel; bring that to the attention to your primary care physician. Have them get rheumatology on board.
We, as a specialist group, are very attuned to the features of psoriatic arthritis, aware that nailbed involvement, sausage shaped fingers, toes, insertional pain, classic features and when you couple that with a negative rheumatoid factor, which is often seen in patients who have rheumatoid arthritis and the pattern of joint involvement, again, so distinctive in this diagnosis; we start therapy early. And the therapies that we utilize are drugs like anti-inflammatories, ibuprofen, Naprosyn, drugs like methotrexate or sulfasalazine or Plaquenil. These are disease modifiers and then finally biologics.
But we are getting much more adroit at giving monoclonal antibodies early which is why direct to consumer advertising has become so prevalent when you have folks like Cyndi Lauper coming to Novartis and saying I’ve got terrible skin disease; my joints are killing me. I need a drug like your drug Cosentyx. Cosentyx is a very specific targeted monoclonal which identifies a specific cell set, the TH17 cells which express IL17 which is a cytokine protein which is implicated in the disease state. That is about as complex as I will get.
Tumor necrosis factor inhibitors also work, drugs like Enbrel, Humira, Cimzia, Simponi. We have a whole host of options including oral immunomodulators, Xeljanz, Olumiant. These are all molecules coming forward as candidate drugs for the treatment of psoriatic arthritis. But the first and most important element is disease awareness. Look for it, understand it, refer it, get treated early, don’t wait. You don’t want to be a victim of this disease progression.
Host: Wow. You are amazing Dr. Krant. What a rockstar you are and to help prevent that long-term structural damage and disability. I’m so glad that you pointed out about early awareness and all of these medications. If people have been on medications that they thought, they just had rheumatoid arthritis; are they just not working as well? Do those same kind of medications you might take for rheumatoid arthritis just not work that well for psoriatic?
Dr. Krant: So, that’s a great point. And the answer is we don’t know who is the right mix in terms of the disease response to a given agent. The drugs that we utilize routinely in rheumatoid arthritis management are often borrowed in the domain of psoriatic arthritis and ankylosing spondylitis, inflammatory back disease. But they don’t always work. That’s the key where we have more and more targeted therapeutics that identify cell specific cytokines or molecules which are implicated in the pathogenesis, the inflammatory presentation of the disease.
And therefore, the fact that Humira may work in a patient with RA, it doesn’t mean that his neighbor with RA is going to respond. In the same manner, the fact that a biologic will work for a patient with psoriatic arthritis doesn’t imply that it is going to work for everybody with psoriatic arthritis. So, we are in a bit of hit and miss situation.
I think the holy grail is to identify genetically susceptible individuals and then understand who fits the specific profile of disease response to a given molecule. That would save our government hundreds of millions of dollars, the pharmaceutical industry would have very specific mandates to design targeted therapies which will then be embraced once we know what genotype, what specific genetic linkage there is between a given individual and their disease.
That said, we borrow the same molecules from oncology, from rheumatoid arthritis care in the management of psoriatic arthritis with actually very, very good success. But more and more drugs are coming forward. There are more candidate molecules under clinical research, in trial and as we go forward, we will be seeing less and less of the standard therapeutics and more and more of the more specific targeted drugs as we go along. And that’s where the idea of drug development has become so relevant in clinical practice. And toward that end, I would encourage all my rheumatology colleagues to get involved in clinical research because this is the cutting edge of patient care.
Host: Wow, it certainly is. Now what about for patients, before we wrap up Dr. Krant, what can they do as far as lifestyle, exercise, diet? Do any of those things affect their psoriatic arthritis?
Dr. Krant: Well there is no doubt that diet plays a role. It’s not as well enumerated as say in osteoarthritis where additional weight translates to excessive force on weightbearing joints. But the same principles apply, becoming lean, watching your diet, omega 3 fatty acids, fish oils, terrific choices just as is the case in rheumatoid arthritis. Cutting down on carbohydrates, stopping smoking, especially when damage to the lungs then obviates the use of medications which may also cause lung involvement, drugs like methotrexate. We are always wondering about how certain medicines can affect lung function. But globally speaking, we want lean, trim, healthy folks who are able to exercise and not limited by pain and that’s why the biologics in conjunction with disease modifiers often anti-inflammatories and on occasions steroids, all play a role in the management of psoriatic arthritis.
Disease awareness is the key. If you have got psoriasis, you’ve got funky looking nailbeds, your big, large weightbearing joints are killing you, don’t wait. Make sure you show up to your primary care physician’s door, get an early referral to rheumatology. We are happy to see you. The light’s on. Don’t be a stranger.
Host: What a great segment and a fascinating interview and topic Dr. Krant. Really people see it on commercials, and they don’t even understand what it is, and you are such an amazing educator. Thank you again for coming on and letting us know all of the many treatment options and the latest advances for psoriatic arthritis. You’re listening to Memorial Health Radio with Memorial Health System. For more information, please visit www.mhsystem.org, that’s www.mhsystem.org. This is Melanie Cole. Thanks so much for tuning in today.
Melanie Cole (Host): People who have psoriasis can also develop a condition called psoriatic arthritis which can cause pain, stiffness, and swelling in and around the joints. My guest today, is Dr. Jonathan Krant. He’s the Medical Director in the Department of Rheumatology at Memorial Health System. Dr. Krant, tell us about psoriatic arthritis. We’re hearing about it in the media, seeing commercials about it. Is this a new condition? Has it been around a while? Or are we just now learning about it?
Jonathan David Krant, MD, FACP (Guest): Well psoriatic arthritis is an extraordinarily interesting topic and it has achieved a lot of local interest especially when you have folks like Cyndi Lauper talking about Cosentyx and Phil Mickelson about Humira and Enbrel. We have a lot of celebrities who are bringing this disease state to our awareness and of course, it’s been around forever. We have just not been that good at recognizing it.
When we look at the domain of psoriasis and psoriatic arthritis it seems that about 30% of folks who have got guttate psoriasis which is the usual psoriatic plaque that one sees on the scalp, elbows, knees, about 30% of folks with psoriasis vulgaris or guttate disease will go on to develop arthritis. And the arthritis is typically a small joint in the distal interphalangeal joints of the fingers, the guys who have your nailbeds on them, in addition to a large weightbearing joint, usually a knee, an ankle. It’s very different from rheumatoid arthritis. It’s not a symmetric small joint process. It’s a generalized large joint arthritis often, but not always seen in the setting of psoriasis.
The things that make this particularly of interest are that a lot of the features of psoriatic arthritis occur outside the joint. You could have a hot, swollen digit, a condition called dactylitis. You can have insertional pain of the Achilles where the Achilles tendon inserts into bone, that’s called enthesitis. There are other spots, spots as well. The elbows, the knees. It’s a remarkable phenomenon and when you couple that with tenderness over the sacroiliac joints, sacroiliitis and a hot inflammatory eye, uveitis; you have got this broad spectrum of disease activity. Negative rheumatoid factor, nailbed involvement with pitting and ridge formation, separation from the nailbed, the nails that is, plus psoriasis, plus these interesting features dactylitis, enthesitis. Have I intrigued you yet? If not, I’ll keep going.
Host: You absolutely have and it’s fascinating and as you say, there’s Cyndi Lauper and we see all these commercials. Who would spot this Dr. Krant? Would that be you go to your dermatologist, you’ve got some issues with your nailbeds or your skin or you see your primary care provider because you’re in pain or even your orthopod because you’ve got Achilles problems? Who diagnoses this?
Dr. Krant: So, that’s a great question. For years I’ve been advocating a partnership between pharmacy - with the pharmaceutical industry and clinicians to develop a community disease awareness ambassador program. These are folks who would be hairdressers or folks working in nail salons who are educated with a very simple slide deck to recognize folks who have pitting of nailbeds, psoriasis of the scalp and are referred on very, very quickly to rheumatology directly. Unfortunately, we are not there yet. We are flushing out some initiatives along those lines, but the usual suspects are the primary care physicians, nurses, nurse practitioners, PAs. The front line folks will see the psoriasis, hear the complaints about joints and say go take some aspirin or some Advil and we will see you in the morning.
Typically, though, things don’t get better, they progress and one of the features that we are aware of is untreated, this disease will form deforming arthritis as well as cause major organ involvement in some cases, all of which can be obviated if we are early disease awareness ambassadors, that is everyone of us. If you have a relative with psoriatic skin who is complaining of joint pain, bring it to your physician’s attention. If your physician is giving you anti-inflammatories, but not thinking about biologic therapies drugs like Cosentyx or Humira or Enbrel; bring that to the attention to your primary care physician. Have them get rheumatology on board.
We, as a specialist group, are very attuned to the features of psoriatic arthritis, aware that nailbed involvement, sausage shaped fingers, toes, insertional pain, classic features and when you couple that with a negative rheumatoid factor, which is often seen in patients who have rheumatoid arthritis and the pattern of joint involvement, again, so distinctive in this diagnosis; we start therapy early. And the therapies that we utilize are drugs like anti-inflammatories, ibuprofen, Naprosyn, drugs like methotrexate or sulfasalazine or Plaquenil. These are disease modifiers and then finally biologics.
But we are getting much more adroit at giving monoclonal antibodies early which is why direct to consumer advertising has become so prevalent when you have folks like Cyndi Lauper coming to Novartis and saying I’ve got terrible skin disease; my joints are killing me. I need a drug like your drug Cosentyx. Cosentyx is a very specific targeted monoclonal which identifies a specific cell set, the TH17 cells which express IL17 which is a cytokine protein which is implicated in the disease state. That is about as complex as I will get.
Tumor necrosis factor inhibitors also work, drugs like Enbrel, Humira, Cimzia, Simponi. We have a whole host of options including oral immunomodulators, Xeljanz, Olumiant. These are all molecules coming forward as candidate drugs for the treatment of psoriatic arthritis. But the first and most important element is disease awareness. Look for it, understand it, refer it, get treated early, don’t wait. You don’t want to be a victim of this disease progression.
Host: Wow. You are amazing Dr. Krant. What a rockstar you are and to help prevent that long-term structural damage and disability. I’m so glad that you pointed out about early awareness and all of these medications. If people have been on medications that they thought, they just had rheumatoid arthritis; are they just not working as well? Do those same kind of medications you might take for rheumatoid arthritis just not work that well for psoriatic?
Dr. Krant: So, that’s a great point. And the answer is we don’t know who is the right mix in terms of the disease response to a given agent. The drugs that we utilize routinely in rheumatoid arthritis management are often borrowed in the domain of psoriatic arthritis and ankylosing spondylitis, inflammatory back disease. But they don’t always work. That’s the key where we have more and more targeted therapeutics that identify cell specific cytokines or molecules which are implicated in the pathogenesis, the inflammatory presentation of the disease.
And therefore, the fact that Humira may work in a patient with RA, it doesn’t mean that his neighbor with RA is going to respond. In the same manner, the fact that a biologic will work for a patient with psoriatic arthritis doesn’t imply that it is going to work for everybody with psoriatic arthritis. So, we are in a bit of hit and miss situation.
I think the holy grail is to identify genetically susceptible individuals and then understand who fits the specific profile of disease response to a given molecule. That would save our government hundreds of millions of dollars, the pharmaceutical industry would have very specific mandates to design targeted therapies which will then be embraced once we know what genotype, what specific genetic linkage there is between a given individual and their disease.
That said, we borrow the same molecules from oncology, from rheumatoid arthritis care in the management of psoriatic arthritis with actually very, very good success. But more and more drugs are coming forward. There are more candidate molecules under clinical research, in trial and as we go forward, we will be seeing less and less of the standard therapeutics and more and more of the more specific targeted drugs as we go along. And that’s where the idea of drug development has become so relevant in clinical practice. And toward that end, I would encourage all my rheumatology colleagues to get involved in clinical research because this is the cutting edge of patient care.
Host: Wow, it certainly is. Now what about for patients, before we wrap up Dr. Krant, what can they do as far as lifestyle, exercise, diet? Do any of those things affect their psoriatic arthritis?
Dr. Krant: Well there is no doubt that diet plays a role. It’s not as well enumerated as say in osteoarthritis where additional weight translates to excessive force on weightbearing joints. But the same principles apply, becoming lean, watching your diet, omega 3 fatty acids, fish oils, terrific choices just as is the case in rheumatoid arthritis. Cutting down on carbohydrates, stopping smoking, especially when damage to the lungs then obviates the use of medications which may also cause lung involvement, drugs like methotrexate. We are always wondering about how certain medicines can affect lung function. But globally speaking, we want lean, trim, healthy folks who are able to exercise and not limited by pain and that’s why the biologics in conjunction with disease modifiers often anti-inflammatories and on occasions steroids, all play a role in the management of psoriatic arthritis.
Disease awareness is the key. If you have got psoriasis, you’ve got funky looking nailbeds, your big, large weightbearing joints are killing you, don’t wait. Make sure you show up to your primary care physician’s door, get an early referral to rheumatology. We are happy to see you. The light’s on. Don’t be a stranger.
Host: What a great segment and a fascinating interview and topic Dr. Krant. Really people see it on commercials, and they don’t even understand what it is, and you are such an amazing educator. Thank you again for coming on and letting us know all of the many treatment options and the latest advances for psoriatic arthritis. You’re listening to Memorial Health Radio with Memorial Health System. For more information, please visit www.mhsystem.org, that’s www.mhsystem.org. This is Melanie Cole. Thanks so much for tuning in today.
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