ReportWire

Tag: biologic

  • How Treating Psoriatic Disease Has Changed

    How Treating Psoriatic Disease Has Changed

    By Nilanjana Bose, MD, as told to Susan Bernstein

    I am an adult rheumatologist, so I see patients who are 18 and above, with the whole gamut of rheumatologic conditions. Every patient I see is different. For patients with classic psoriatic disease, skin psoriasis symptoms often occur before their arthritis symptoms happen. These two conditions could even develop years apart for some people. But that’s not absolute. You can develop arthritis, or joint pain and swelling, first and then later develop psoriasis.

    Patients typically first come to see us for their joint swelling. Usually, psoriatic arthritis causes a peripheral joint swelling. They’ll have swelling of your fingers and toes, which can look similar to rheumatoid arthritis (RA). We do an initial workup and examine their skin, too. If they have psoriasis, including nail pitting or psoriasis plaques, or if they have a family history of psoriasis or psoriatic arthritis, this may suggest that they may have psoriatic arthritis.

    COVID: Hello, Telehealth

    Once the pandemic hit last year, for the first couple of months, we had to go into retreat mode at our clinic. We really had to scramble to adapt. We moved quickly into using telehealth to treat our patients. We didn’t have some of the telehealth technology, but once we understood that there were resources out there, like telehealth portals and online platforms we could use, we started adopting them.

    I think our patients also adapted to telehealth fairly quickly. There were some challenges with older folks. Some didn’t have internet access or found it harder to work out the logistics of telehealth. But for those patients, we were able to conduct regular telephone visits as well.

    Telehealth came with its own challenges. We had to learn how to “examine” a patient over the internet. It’s not easy, and it’s not optimal for joint or skin conditions. But a telehealth visit is any day better than a patient missing their appointment altogether and not accessing medical care.

    For follow-up visits, telehealth is easy and works well. You can check in with patients and see how they’re doing on their current medications. Some of my patients really prefer telehealth for the convenience. Again, it’s not optimal. We still encourage our psoriatic disease patients to come into the office. It can be tough to see everything using the camera.

    Overall, telehealth has been a fun experience, but if a patient needs to be examined in person, I ask them to come in. We’re all still masked up, practicing social distancing, and taking every precaution. We are very committed to the whole aspect of infection control with our patients.

    I’ve even seen new patients using telemedicine, especially during the worse phases of the COVID pandemic. If they were referred to me by another physician because they have psoriasis, I can do the initial consultation remotely, but I still try to have them come in. Just getting in and seeing a rheumatologist to begin your treatment is ultimately the most important step with psoriatic disease. You can establish a rapport with your doctor and get the information you need.

    Biologics: Game Changer for Psoriatic Disease

    Biologics have totally changed the way we manage this disease. Once you’re diagnosed with psoriatic arthritis, there are great treatment options out there. In the past, we had steroids, DMARDs (disease-modifying antirheumatic drugs), and TNF inhibitors, but now, we have IL-17 and IL-23 inhibitors, and JAK inhibitors, too.

    Initially, we evaluate our new patients with lab tests and joint imaging and go over all of their symptoms. Some people will have milder psoriatic disease, and some will have more systemic symptoms. With younger patients, we may try to be more aggressive at controlling their disease, because they’re at greater risk for joint damage.

    When we go over treatment options, it’s really a two-way, fluid discussion. I talk with my patients about all the risks and benefits of each treatment. If my patient is doing better after a few months, we talk about it and may re-assess the treatment plan.

    It’s very rare to see people with psoriatic arthritis these days who develop chronic joint deformities. It may happen if someone was diagnosed a long time ago, before there were better treatment options, or if they were unable to access care before they came to us. The improvements are mainly due to advances in drug treatment, but also because people are more conscious of rheumatic diseases. They Google it. They just have more awareness of rheumatic conditions and that they need to see a rheumatologist.

    We screen every patient. Some of them have a true inflammatory, psoriatic disease, while some do not. They may have osteoarthritis or fibromyalgia causing joint pain. Every patient deserves a thorough, complete examination. We want to diagnose these patients as early as possible to begin treatment to control their disease and prevent damage.

    COVID and Other Infections: Take Extra Precautions

    We were having this exact discussion with our patients before COVID, too. They are at higher risk for serious infections – not just COVID, but also other types of pneumonia and other infections. We had already been encouraging these patients to wash their hands often, take commonsense precautions, avoid close contact with sick people, and to get all their vaccinations.

    Once the COVID vaccines became available, I told them, “Please get vaccinated and keep wearing your mask.” People who are on a biologic to treat their psoriatic disease are by default more cautious. For new patients who were just starting their biologics, I advised them on how to take precautions to prevent infection. We told many of our psoriatic patients, “Stay home as much as you can right now, and avoid close contact with others.” Patients do listen to this advice because they trust us as their doctors.

    Making Psoriatic Patients Feel Safer

    Always have a backup plan with telehealth technology! Also, I have encouraged all of my patients to enroll in our online patient portal, so we can stay connected. They can send me messages, I can update their prescriptions, and we can share test result with them.

    Technology is a beautiful thing. We need to use it to the fullest advantage in modern medical care. Technology can make it easier to stay in touch with patients with psoriatic disease, who need ongoing care. But some patients may not be used to telehealth, so they can experience some frustration at first. Be patient, take your time to learn to use these tools, and help your patients adapt. Don’t give up if something doesn’t work right at first.

    Face-to-face interaction is still very important when you are working with patients with psoriatic arthritis. It can be difficult to form a new patient/doctor relationship without any in-person component.

    After they’re diagnosed, some patients continue to see me virtually, and it seems like we are really able to get to know each other well. Telehealth is a safe, secure environment for patients. They’re in their home or office, or even in their car. Sometimes, when I’m talking with a psoriatic patient over telehealth, I see them taking notes. That’s good! Some people find that they’re less anxious when they’re in a telehealth appointment instead of being in their doctor’s office.

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  • My Journey to Treating With a Biologic

    My Journey to Treating With a Biologic

    By Julie Greenwood, as told to Keri Wiginton

    Biologics gave me my life back. Once I took the medicine, my skin became human again. And I changed from a person who couldn’t function at all to someone who’s been able to work for years.

    I tried my first biologic in 2003. But that’s not where my story begins.

    When my psoriatic disease started in 1991, my dermatologist put me on methotrexate right away. That’s a drug used to treat joint inflammation, but I didn’t know anything about it. I was only 23, and they gave me this pill with no mention of side effects. It made me so sick that I decided to stop taking it.

    But I have severe psoriatic disease. Over the years, it continued to progress. My fingers swelled up like sausages. I couldn’t step off a curb unassisted or stand up straight. I was hunched over like a little old woman because my back hurt so bad.

    My skin symptoms got worse, too. My psoriasis started in my scalp, then showed up in my ears and went down my back to just below my knees. My skin was so tight that just moving would make it crack and bleed.

    It felt like I was wearing reptile skin.

    Years of Frustration

    I tried all kinds of things to make my skin more human. I even ordered a product from the back of a magazine. It was banned in the U.S, and it burnt my skin. But it also got rid of my plaques. I have scars under my breasts from it.

    But I was desperate. I would’ve put acid on my skin if it would’ve worked.

    I also tried messy steroid creams. But I could only get them with a prescription. My doctor would give me this tiny little tube for a whole month. I have psoriasis all over my body, so that tube would last maybe a few days.

    I also tried something called Goeckerman therapy. They put me in a UVB-light machine in the mornings. Then they’d slather me in coal tar and cover me in plastic wrap and I’d sit in a room all day. And this was before we had smartphones to entertain ourselves.

    That worked, but only for a few weeks.

    Then, when I was 31, I got pregnant. My symptoms went into complete remission. I hoped my body would forget I had psoriatic disease. But everything started up again a couple of months after my daughter was born.

    Finding a Biologic

    I thought that if pregnancy could put me into remission, there must be something that could help me feel better. I was determined to find that treatment. My dermatologist put me in a study where they gave me a diabetic medicine. It was amazing. But then they changed me to a different study drug, and my symptoms came back.

    I went back to my doctor and asked, “What else do you have?” Then he told me about a biologic drug. At first, I said no. I wasn’t interested in giving myself a shot. I was terrified of needles.

    That’s when my doctor gave me some tough love.  He said I’d have to go to someone else if I wasn’t willing to try it and that there wasn’t anything else he could do for me.

    That sounds really harsh when I say it out loud. But I understand why he said it like that.

    My doctor went over all the pros and cons of biologics. I didn’t have the same kind of fear about this drug that I did about methotrexate. I think the main reason was because I’d gone through so much pain during the previous 10 years. What’s more, I’d had those months of remission, so I knew what it felt like to feel good again.

    When My Symptoms Improved

    I found it very hard to give myself that first shot. But I did it in my doctor’s office. A couple of days after that first shot, I remember saying to my parents, “I might be crazy, but I think I’m starting to feel better.”

    Within a couple of weeks, my skin started to clear up. And it was completely clear after about 6 weeks. But what was really noticeable was that after only 2 weeks, I could walk like a normal person. My constant pain eased.

    Biologics helped me do everyday things that people without psoriatic disease might take for granted. I could do normal mom things, like pick my daughter up and put her in the sink to take a bath. Not long after that, I could lean over to put her in the bathtub. I could bend and stretch my body without cracking my skin.

    And then there were my sheets. I’d always treated them as disposable. I’d bleed on them, and all the stuff I put on my skin would rub off. I could only keep them for a few months before throwing them out. Now I only have the best sheets.

    Considering Side Effects

    I know that biologics raise your odds for infections. But I wasn’t really worried about that. I was more concerned that’d I’d get cancer or have a seizure. My doctor reassured me and helped me feel better.

    My teenage daughter also has psoriatic disease and is on a biologic. She was very comfortable starting her treatment, partly because I’ve been on them for so long. Plus, I do a lot of advocacy work. I’m always telling people they should be more afraid of the progression of psoriatic disease than of the biologics themselves. She’s heard that so many times that she knew not to let her disease go untreated.

    Now when I look at it, my thought is: If I do have a higher chance of health problems after taking a biologic for so long, at least I’ve boosted my quality of life for all of these years. It would have been so poor without the medicine. That wouldn’t have been a life worth living.

    Changing Biologics

    I’ve been on a different drug for a little more than a year now. I’m always afraid of trying a new medication. It’s the most stressful part about my treatment. I’ve had pretty serious allergic reactions to infusions with biologics before.

    My doctor is very cautious about changing my medicine. They only do it if I stop responding to treatment — my joint inflammation gets worse, for example. When I do make a switch, I’ll ask my husband to check on me through the night.

    Going Forward

    Only recently has my disease made it so I can’t keep working. I was really hard on myself about that. I felt like a failure. But then I remembered something: I worked for three decades beyond my diagnosis. I have to stop and remind myself of what a major achievement that is. I’m actually a badass who’s pretty amazing.

    I still have a moderate level of pain that’s only gotten worse with my age. I’m 52 now. But it’s unbearable to think about what my life would’ve been like without these drugs. I’ve gone through hard times, even recently, with my mental health. But if somehow all of the biologic companies shut down tomorrow, I don’t know what I’d do.

    It takes a lot of effort and energy to live with psoriatic disease. And it’s because of this medication that I can do it. I’m so incredibly thankful. 

    Julie Greenwood is an advocate and volunteer with the National Psoriasis Foundation, National Patient Advocate Foundation, and Patient-Centered Outcomes Research Institute. She lives in Cary, NC, with her husband, Scott, daughter, Nora, and their two puggles, Molly Malone and Cassie.

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