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Tag: rheumatologist

  • How Treating Psoriatic Disease Has Changed

    How Treating Psoriatic Disease Has Changed

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    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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  • Psoriatic Disease: An Autoimmune Disease Expert’s Point of View

    Psoriatic Disease: An Autoimmune Disease Expert’s Point of View

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    By Brett Smith, DO, as told to Rachel Reiff Ellis

    Psoriatic disease is a condition you have your whole life. Skin plaques are the main symptom, but many people also get joint pain. It requires lifelong observation by medical professionals. Although there isn’t a cure for psoriatic disease, there are great medications to help control the symptoms.

    The news that you have it can sometimes come as a surprise. You may see your primary care doctor because you’re having joint pain, but be unaware of plaques because they’re hiding on your backside, scalp, chest, or groin.

    If your psoriasis is mild enough, a primary care doctor should be able to prescribe topical steroids or other topical medications to help, depending on how much of your body is involved.

    But many people with psoriasis require more than just topical therapies, especially if they have joint pain and swelling. If your psoriasis care goes beyond the scope of a primary care doctor, you’ll need to see other specialists to get the treatment you need.

    Your Health Care Team

    After you’re diagnosed, you’ll primarily see a dermatologist. If you have joint pain, you’ll see a rheumatologist. As a rheumatologist myself, I get referrals from primary care doctors, dermatologists, and sometimes pediatricians.

    About 30% of people with psoriasis go on to have joint inflammation. On average, that inflammation comes about 10 years after a psoriasis diagnosis. When people with psoriasis have joint pain, a dermatologist refers them to me. A collaborative approach with a dermatologist gives people the best care.

    You may have to see other specialists along the way, depending on how your psoriatic disease affects you. There are people with joint inflammation who get inflammatory eye problems or intestinal problems later. You’ll need an eye specialist or a gastroenterologist to help you with that.

    Make the Most of Your Appointments

    When you meet with your doctor, especially for your first visit, come with questions and details that cast a wide net. Talk about any symptoms you’re having, even if they don’t seem related to psoriatic disease. Your doctor will want to know if they should look anywhere else for information, like your eyes, gastrointestinal tract, or nails. If you’re having joint or back pain, ask about an evaluation by a rheumatologist.

    Find out about the specific medications you’ll be taking:

    • How often will I take it?
    • How will I take it?
    • What are the possible side effects?
    • What are the goals of treatment?
    • How soon should I expect to see a difference in my symptoms?

    Treatment will vary, depending on your diagnosis and condition. But in general, everyone with joint inflammation from psoriatic disease should be taking medication unless there’s a specific reason that it would be risky for you. Most people are going to feel at least 50% to 75% better within the first 3-6 months of therapy, and even better beyond that.

    Remission — meaning no joint swelling, no pain — isn’t possible for everybody, unfortunately. But we shoot for that goal, because if you’re that person, we want to have you there.

    Stay in Touch

     

    Check in with your doctor every 6 months or so. When psoriatic disease affects the joints, it’s chronic and can be quite aggressive in terms of damage and chronic pain, so you want to make sure your joints are OK.

    Aside from that, you should make a visit to your doctor if your pain gets worse, you notice a swollen joint, you feel stiffer, or your back hurts more.

    Your doctor will also want to know if you have inflammation or pain in one or both of your eyes, or if you have diarrhea or blood in your stool. This could be a sign that your disease is affecting more of your body. In that case, you might need a new therapy that can treat all those things better.

    Don’t underestimate how aggressive the disease can be. You’re more likely to have problems from the disease than you are from the medications you take. Psoriasis can come on at a fairly young age — many people are between 20 and 30 years old when they find out they have it.  So that can be a long time for the disease to be active in your body.

    We can always change therapies and find one that works best for you.

    The goal is to find medication that will help you be comfortable. I know that sometimes the medication can seem intimidating or scary, but we have a lot of experience with them. These medicines can really help.

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  • Should You Stay or Go? When to Change Treatments

    Should You Stay or Go? When to Change Treatments

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    Treating psoriatic arthritis (PsA) isn’t like treating strep throat. You don’t just take one medicine for a few days and feel better. PsA is a complex, chronic disease that stays with you and affects many parts of your body — skin, joints, nails, heart, and lungs.

    Many medications slow PsA and relieve symptoms, but the first treatment you try won’t always be the right one for you.

    “There is no one-size-fits-all, and there is no one medication for psoriatic arthritis,” says Saakshi Khattri, MD, assistant professor of dermatology and rheumatology at the Icahn School of Medicine at Mount Sinai in New York. “So often there are patients who do not respond to their medication.”

    There are a couple of reasons you might need to switch to a new treatment, says Ethan Craig, MD, assistant professor of clinical medicine at the University of Pennsylvania and rheumatologist at the Corporal Michael J. Crescenz VA Medical Center in Philadelphia.

    “One is intolerance — the patient has a side effect of some sort. The second is ineffectiveness. Either the medication doesn’t work in the first place, or it works for a period of time and then it stops working,” he says.

    When your medicine doesn’t tame your symptoms, it’s time to regroup with your rheumatologist or dermatologist and talk about other treatment options.

    Signs That It’s Time to Change

    The clearest signs that you need a medication switch is a new flare-up of symptoms.

    Worsening joint pain and stiffness, increased fatigue, and sudden trouble doing activities that were easy for you are some of the most obvious symptoms. More subtle signs like difficulty sleeping and mood changes also suggest the medication you’re on isn’t controlling your PsA well enough.

    If you’ve just started on a treatment, you do need to give it time. 

    Sometimes you can have a partial response — maybe the swelling comes down in some of your joints but not in others. Then your doctor might suggest that you wait it out for 4 to 6 months to give the drug more time to work. During that time, steroids or nonsteroidal anti-inflammatory drugs (NSAIDs) can help bridge the gap until your medication kicks in.

    Once you’ve been on a treatment for several months with no improvement, or if you’re no longer getting relief from a drug you’ve been taking for a while, “that’s often an indication that we need to think about switching things up,” Craig says.

    Advice for Switching Meds

    PsA treatment comes in many forms. Often anti-inflammatories and conventional disease modifying drugs are used (DMARDS). Biologic DMARDS are also often used; they target different pathways in the immune system. There are other options for treatment as well, including targeted synthetic DMARDS and newer oral agents.

    Your doctor will take a few factors into consideration when recommending your next step, including:

    Your symptoms. PsA causes a variety of symptoms. Your choice of medication may hinge on the type of symptoms you have, how much they bother you, and which drug targets them best.

    For example, one of Craig’s patients worked at a ticket window. “Because he had to hand out tickets, he was very self-conscious about the appearance of his nails,” Craig says. “He was willing to be on a drug that helped his nails, even if it didn’t help his arthritis.”

    The drug’s side effects. Each type of medication comes with a set of side effects, which you need to balance against its benefits. For example, methotrexate can irritate your stomach, while biologics increase the risk for infections. It’s important to think about which side effects you can tolerate and which ones you definitely don’t want.

    How you take the drug. Many PsA meds come as an infusion or an injection. If you’re not a fan of needles, you might prefer a pill.

    What other conditions you have. Methotrexate can damage your liver. NSAIDs are linked to heart problems. So if you already have liver or heart disease, these medications may not be safe for you.

    Your insurance coverage. Ultimately, your insurance company could decide which treatment you get next. “The sad fact of the matter is that our choice of medication is often substantially constrained by insurance approval,” Craig says.

    Some insurance companies will expect you to try a certain drug first and prove it doesn’t work before they’ll let you switch to the medication that you and your doctor want to use.

    How to Ask Your Doctor for a New Treatment

    You might already see your doctor every 3 to 4 months if you take medication. During those visits, the doctor can examine your joints, do imaging tests, and check your lab test results to see whether your PsA is under good control.

    But tests don’t always tell the whole story. Your point of view is important, too. Let the doctor know if you’re having any problems with your medications, including side effects or breakthrough symptoms.

    If you’re not due for a visit yet, call the office or send your doctor an email about your concerns through the patient portal.

    Don’t be afraid to speak up. “A lot of patients are hesitant. They don’t want to take up the doctor’s time,” Craig says. “It’s helpful for us if they come in. I hate to see someone suffer for months. And it’s often easier to intervene earlier in the course of the disease, when things are less active.”

    If your doctor isn’t on board with you switching medications, don’t be afraid to push back to get on the right treatment. “Sometimes it’s a matter of miscommunication,” he adds. “We need to be on the same page as to what the expectations are, what we’re treating, and what effect we expect.”

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