Physicians in the Center for Skin and Related Musculoskeletal Diseases, part of the Brigham and Women’s Hospital Orthopedic and Arthritis Center, have developed an innovative approach to care for patients with psoriasis and joint pain that enhances diagnostic accuracy and appropriate treatment choices.
The Center for Skin and Related Musculoskeletal Diseases at Brigham and Women’s Hospital (BWH) offers a unique therapeutic approach to treating patients with concomitant systemic rheumatic and skin disease. Center Co-directors Elinor A. Mody, MD, a rheumatologist, and Abrar A. Qureshi, MD, MPH, a dermatologist, see all patients together to provide comprehensive care for diseases with both musculoskeletal and cutaneous manifestations.
They have a particular clinical interest in psoriasis and psoriatic arthritis, and both physicians agree that as a multidisciplinary team they can provide better clinical care than either could alone.
Drs. Mody and Qureshi, along with Elaine Husni, MD, published a description of their innovative approach in Seminars in Cutaneous Medicine and Surgery. They observed that psoriatic arthritis is challenging to diagnose and treat, and that a team approach is ideally positioned to identify and manage patients who suffer from both psoriasis and psoriatic arthritis.
Multidisciplinary approach enhances diagnosis
Musculoskeletal pain in patients with psoriasis is not necessarily an indication of psoriatic arthritis. At the recent World Congress of Psoriasis and Psoriatic Arthritis in Stockholm, Dr. Mody presented findings from a study of 71 patients with psoriasis and joint pain seen in the Center for Skin and Related Musculoskeletal Diseases. Both a rheumatologist and a dermatologist assessed patients, and only 41 percent actually had psoriatic arthritis. Of the remaining group, 27 percent were diagnosed with osteoarthritis alone, three percent with gout, 14 percent with both osteoarthritis and psoriatic arthritis, and 14 percent with no specific disease.
New diagnostic tool will aid differential diagnosis
According to Dr. Mody, “Physicians need to have a more definitive process to evaluate patients with psoriatic arthritis and joint pain. Psoriatic arthritis may be progressive and crippling, and patients require early and aggressive intervention in order to prevent joint damage.”
To address this need, Dr. Mody and Dr. Qureshi have developed the Psoriatic Arthritis Screening and Evaluation (PASE) questionnaire, a tool to assist physicians in screening patients with psoriasis for evidence of psoriatic arthritis. The tool is a patient-administered questionnaire and a simple scoring system. Patients who score above a certain level have a significantly higher incidence of having psoriatic arthritis and should be further evaluated by a rheumatologist and for advanced treatment. Validation studies show this tool is quite reliable in determining which patients have psoriatic arthritis, and especially which patients have significant disease requiring DMARD or biologic therapy. Drs. Mody and Qureshi also follow changes in PASE scores after patients begin therapy. (To learn more about PASE, contact Dr. Mody at the e-mail address listed at the end of this article.)
Advanced treatments
An experienced rheumatologist also should evaluate patients with some degree of psoriatic arthritis and a significant degree of skin involvement. Although the musculoskeletal and cutaneous symptoms may be manageable with anti-inflammatory and topical medications, the complete clinical picture suggests that the patient may benefit from systemic treatment.
Dr. Mody says, “Because of our multidisciplinary experience and expertise, our psoriasis and psoriatic arthritis patients have early and expert access to TNF inhibitors and other agents commonly used to treat inflammatory diseases. I believe that ultimately the therapeutic paradigm for psoriatic arthritis will change, and clinicians will adopt an acute therapy approach consisting of aggressive treatment with several effective drugs to achieve remission and re-treatment as necessary to prevent relapse.”
Prognostic indicators may help tailor therapy
Center clinicians have embarked on the development of an ambitious registry of patients with psoriasis and/or psoriatic arthritis. They have enrolled approximately 100 of an anticipated 1,000 patients, and collected demographic information, history, and clinical data including blood, skin, and synovial fluid samples, treatments, side effects, and outcomes.
This is one of the first natural history observational studies of this type of patient group. Dr. Mody’s hope is that the registry will provide some prognostic indictors that clinicians could use to predict the course of an individual patient’s disease and tailor therapy accordingly.
Clinical trials advance patient care
Dr. Mody is principal investigator at BWH for a longitudinal study to assess the safety effects of etanercept, commercially available as Enbrel, in patients with plaque psoriasis. This is a phase IV prospective, multi-center observational surveillance registry to gather and evaluate data on the long-term safety of etanercept. Unlike previous phase III studies, patients with significant underlying diseases or concomitant use of certain other antipsoriatic agents will not be excluded. Dr. Mody expects to enroll approximately 50 patients for whom etanercept is clinically indicated and to follow them for five years to determine the incidence of serious adverse events and serious infectious events.
In addition, Center physicians are developing clinical trials, including trials to determine optimum dosing for existing biologic therapies, and investigation of biologics currently used to treat other diseases to determine if they may have a role in treatment of psoriasis and psoriatic arthritis.
For information about PASE or to inquire about clinical trials, please contact
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