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 Faculty Kori Dewing, ANP-BC, DNP, ARNP  Faculty Kori Dewing, ANP-BC, DNP, ARNP

Faculty Kori Dewing, ANP-BC, DNP, ARNP - PowerPoint Presentation

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Faculty Kori Dewing, ANP-BC, DNP, ARNP - PPT Presentation

Rheumatology Nurse Practitioner University of Washington School of Nursing Affiliate Assistant Professor Seattle WA Dr Dewing has no conflicts of interest to disclose Please complete the preactivity survey ID: 775437

psoriasis psa arthritis dermatol psoriasis psa arthritis dermatol patients treatment disease acad joint 2016 rheumatol symptoms risk severe skin

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Slide1

Slide2

Faculty

Kori Dewing, ANP-BC, DNP, ARNPRheumatology Nurse PractitionerUniversity of Washington School of NursingAffiliate Assistant ProfessorSeattle, WA

Dr. Dewing has no conflicts of interest to disclose.

Slide3

Please complete the

pre-activity survey.

Slide4

This program is supported by educational funding provided by Novartis Pharmaceuticals and Amgen.

Slide5

To download a pdf of the slides, please visit:

http://www.cmecorner.com/PDF/psor-psaCES.pdf

Slide6

Learning Objectives

Upon completion of this educational activity, participants should be able to:

Summarize the epidemiology and pathophysiology of psoriasis and

PsA.

Describe the diagnosis, disease classification, and assessment associated with psoriasis and

PsA.

Incorporate patient preferences and shared decision making into tailored treatment plans for patients with psoriasis and

PsA.

Evaluate the efficacy and safety of recently available therapies for the management of psoriasis and

PsA.

Slide7

Psoriasis

Slide8

Psoriasis

Chronic, immune-mediated skin diseaseMost common autoimmune diseaseCorrelation between skin and systemic inflammationHigh comorbidity burdenAffects almost 8 million Americans

Rachakonda

TD, et al.

J Am

Acad

Dermatol

. 2014;70(3):512-516; Eder L, et al.

Arthritis

Rheumatol

. 2016;68(4):915-923;

Helmick CG, et al.

Am J Prev Med

. 2014;47(1):37-45;

Nestle FO, et al.

N

Engl

J Med

. 2009;361(5):496-509.

Slide9

Psoriasis

Tollefson

MM, et al. J Am Acad Dermatol. 2010;62(6):979-987; Icen M, et al. J Am Acad Dermatol. 2009;60(3):394-401; Rachakonda TD, et al. J Am Acad Dermatol. 2014;70(3):512-516; Helmick CG, et al. Am J Prev Med. 2014;47(1):37-45.

Psoriasis in Adults (n=2564)

Pediatric incidence: 40.8/100,000 population

Adult incidence: 78.9/100,000 population

Slide10

Impact of Psoriasis on

QoL

Emotional and Physical Impact of Psoriasis

Psoriasis Patients (%)

Adapted by Lilian McVey from Armstrong AW, et al. PLoS One. 2012;7(12):e52935. Used with permission.

~80% to 90% of psoriasis patients experience significant impairment of

QoL

and work productivity

Slide11

Pathogenesis

Ainsworth C.

Nature

. 2012;492(7429):S52-S54. Used with permission.

Slide12

Psoriasis Types

Photos courtesy of Margaret Bobonich, DNP, FNP-C, DCNP, FAANP. Used with permission.

Erythrodermic

Nail psoriasis

Scalp

Genital/Inverse

Plaque

Plaque

Slide13

Psoriasis Assessment: Types

Plaque psoriasisWell-defined erythematous plaquesElbows, knees, scalp, lower trunkScalp psoriasisPresentation ranges from slight scaling to thick, crusted plaques that cover the scalpNail psoriasisNail pitting and crumbling, separation of nail plate from bed with white discoloration, nail thickeningInverse psoriasisShiny, erythematous plaques with minimal scalingGroin and/or other intertriginous areas (eg, under breasts, in abdominal skin folds)

Young M, et al.

J Am

Assoc

Nurse

Pract

.

2017;29(3):157-178.

Slide14

Psoriasis Assessment: Types (cont’d)

Pustular psoriasisEruption of sterile pustulesGeneralized and extensive or localized to existing plaquesPalmoplantar pustular psoriasisYellow-brown sterile pustules on hands and feetMay include scaling and severe pruritisErythrodermic psoriasisGeneralized exfoliative dermatitis, often with hair loss and nail dystrophyAffects large body surface area (BSA); ≥80%Guttate psoriasisSmall, scattered, pink, oval-shaped papules w/silvery scalingAffects trunk and extremities

Young M, et al.

J Am

Assoc

Nurse

Pract

.

2017;29(3):157-178.

Slide15

Psoriasis Assessment

Comprehensive examMedication historyAssess for comorbidityPsoriatic arthritis (PsA) and other arthropathiesDiabetesHyperlipidemiaObesityCardiovascular diseaseMalignancyDepression

Differential diagnosesEczemaContact dermatitisSeborrheic dermatitisDrug eruptionTinea infectionsPityriasis roseaLichen planusCandidal intertrigoOnychomycosis

Psoriasis can be difficult to diagnose…When in doubt, REFER!

Young M, et al.

J Am

Assoc

Nurse

Pract

.

2017;29(3):157-178.

Slide16

Clinical Pearls for Diagnosis

Distribution

Eczema common on flexors

Psoriasis common on extensors

Auspitz

sign

Well-defined

vs eczema with diffuse border

Consider treatment secondary infection

Inverse psoriasis vs candidiasis vs

intertrigo

Skin biopsy if unsure (punch biopsy)

Slide17

Psoriasis Assessment: Severity

Scoring tools:

PASI: Psoriasis Area and Severity Index

BSA: Body Surface Area

DLQI: Dermatology Life Quality Index

Remember:

Severity ≠ amount of area affected

Consider

Area(s) of involvement

Palms, genitals, soles, scalp, nails

Interference with

QoL

Slide18

US Perspectives: MAPP Survey

Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) surveyN=1,005 patients, 101 dermatologists, and 100 rheumatologistsKey findingsBoth psoriasis and PsA remain undertreated in patients with moderate-to-severe diseaseGaps in care include screening, assessing, diagnosing and treating psoriasis patients with symptoms of PsA

Lebwohl

MG, et al.

Am

J

Clin

Dermatol

. 2016;17(1):87-97.

Slide19

US Perspectives: MAPP Survey

Key findings (cont’d)Widespread dissatisfaction with current treatment optionsLack of efficacyLong-term safety unknownAdministration challengesCostDifference in perceptions of severity, treatment impact in patients vs clinicians

Lebwohl

MG, et al.

Am

J

Clin

Dermatol

. 2016;17(1):87-97.

Slide20

Perceptions of Disease Severity: MAPP Survey

Perceptions of disease severity differ between patients and clinicians

Adapted by Lilian McVey from Lebwohl MG, et al. Am J Clin Dermatol. 2016;17(1):87-97. Used with permission.

Respondents (%)

36.1

11.9

21.8

76.2

8.3

4.0

11.4

4.0

5.4

0.0

Most important factors contributing to disease severity in psoriasis, as reported by patients and clinicians

Slide21

Psoriatic Arthritis

Slide22

PsA in Psoriasis Patients

Up to 30% of individuals with psoriasis will develop PsA (higher than previously thought)Risk factorsSevere psoriasisPsoriatic nail pittingUveitis

Eder L, et al. Arthritis Rheumatol. 2016;68(4):915-923.Karreman MC, et al. Arthritis Rheumatol. 2016;68(4):924-931.Photos courtesy of Margaret Bobonich, DNP, FNP-C, DCNP, FAANP.Used with permission.

Slide23

PsA

Inflammatory arthritisSkin disease typically precedes joint diseaseVariable disease courseFlares and remissionSevere disease is associated with:Progressive joint damageIncreased mortalityIncrease in cardiovascular risk

Eder L, et al. Arthritis Rheumatol. 2016;68(4):915-923.Gladman DD. Clin Exp Rheumatol. 2008;26(5 Suppl 51):S62-S65.Arumugam R, McHugh NJ. J Rheumatol Suppl. 2012;89:32-35.Photo courtesy of Margaret Bobonich, DNP, FNP-C, DCNP, FAANP. Used with permission.

80%

20%

Slide24

Diagnosis of PsA

High prevalence of undiagnosed PsA (~10%-15%)Patients with PsA report a mean interval of 12.4 years between onset of skin symptoms and onset of joint symptomsArthritis symptoms precede skin involvement in 13% to 17% of patients15% of patients have undiagnosed or unrecognized psoriasis

1. Villani A, et al. J Am Acad Dermatol. 2015;73(2):242-248.2. Karreman MC, et al. Arthritis Rheumatol. 2016;68(4):924-931.3. Gottlieb A, et al. J Am Acad Dermatol. 2008;58(5):851-864.

Joint symptoms represent DESTRUCTIVE,

IRREVERSIBLE DISEASE.

Early diagnosis is critical for preventing progression.

Slide25

Diagnosis of PsA

Common signs and symptoms Musculoskeletal (32.1%)Joint symptoms (88.2%)Tendon symptoms (50.4%)DactylitisLow back pain (73.9%)Peripheral arthritis Psoriatic nail dystrophy (15.5%) Enthesitis (4.6%-7.0%) Uveitis Plaque psoriasis

Karreman

MC, et al.

Arthritis

Rheumatol

.

2016;68(4):924-931.

Slide26

Diagnosis of PsA

2 primary patternsPeripheral joint disease (~95% of PsA patients)Axial involvement only (~5% of PsA patients)Diagnosis is typically made in a patient with psoriasis and inflammatory arthritis in a PsA-type patternPatients with psoriasis may have other types of arthritis including RA, OA, gout, reactive arthritis, and arthritis of IBD

Gottlieb A, et al.

J Am

Acad

Dermatol

. 2008;58(5):851-864.

Slide27

Diagnosis Is Made Clinically

HistorySkin diseaseJoints involvedEnthesitis, dactylitis, eye disease, inflammatory back pain (age <40, worse at night with AM stiffness, better with activity)Family historyPhysical examLaboratory testingCBCBUN, creatinine, uric acid, and UAESR and CRP (elevated in 40% of patients)RF (2%-10%), anti-CCP (8%-16%) and ANA (low titer 50%)HLAB27 (50%)

ArthrocentesisTo rule out septic arthritis, gout and CPPDImagingPlain film, ultrasound, MRICo-existence of erosive changes and new bone formation, which may occur in same joint or within same digit

Menter A, et al. J Am Acad Dermatol. 2011;65(1):137-174; Alenius GM, et al. Ann Rheum Dis. 2006;65(3):398-400; Johnson SR, et al. Ann Rheum Dis. 2005;64(5):770-772; Eder L, et al. Ann Rheum Dis. 2012;71(1):50-55.

Diagnosis can be

challenging

:

REFER

Slide28

ClASsification Criteria for Psoriatic ARthritis (CASPAR)

Valuable in clinical trials, can be used for diagnosisLimited to peripheral arthritis, axial disease, and enthesitisSpecificity of 98.7% and sensitivity of 91.4%Advantages over Moll and Wright Criteria*High specificity and sensitivityIncludes family history of psoriasisIncludes inflammatory articular diseaseIncludes RF status

*To meet the Moll and Wright 1973 classification criteria for psoriatic arthritis, a patient with psoriasis and inflammatory arthritis who is seronegative for RA must present with 1 of 5 clinical subtypes: polyarticular, symmetric arthritis;

pligoarticular

(less than 5 joints), asymmetric arthritis; distal interphalangeal joint predominant; spondylitis predominant; or arthritis

mutilans

.

Taylor W, et al.

Arthritis Rheum

. 2006;54(8):2665-2673;

Congi

L,

Roussou

E.

Clin

Exp

Rheumatol

. 2010;28(3):304-310; Gottlieb A, et al.

J Am

Acad

Dermatol

. 2008;58(5):851-864.

Slide29

PsA is diagnosed when ≥3 points below are assigned in the presence of inflammatory articular disease (joint, spine, or entheseal)CategoryDescriptionPointsCurrent or personal history of psoriasisPsoriatic skin or scalp disease confirmed by dermatologist or rheumatologist; history of psoriasis from patient, family physician, dermatologist, rheumatologist, or other qualified practitioner 2 Family history of psoriasisPatient-reported history of psoriasis in first- or second-degree relative1Psoriatic nail dystrophy on current physical examIncludes onycholysis, pitting, and hyperkeratosis1Negative for RFEnzyme-linked immunosorbent assay or nephelometry preferred (no latex) using local laboratory reference range1Current dactylitis or history of dactylitis documented by a rheumatologistSwelling of entire digit1Radiographic evidence of juxta-articular new bone formationIll-defined ossification near joint margins excluding osteophyte formation on plain X-rays of hand or foot1

CASPAR

Taylor W, et al

.

Arthritis Rheum

. 2006;54(8):2665-2673.

Slide30

Treatment of Psoriasis and

PsA

Slide31

Treatment of Psoriasis

Type of treatmentRecommended forCommentsTopical Therapy(emollients, corticosteroids, vitamin D analogues, calcipotriene, tazarotene, calcineurin inhibitors, anthralin)Mild disease (standard)Limited by poor adherence ratesUltraviolet (UV) Light(UVB radiation, narrow-band UVB, photochemotherapy [PUVA]) Moderate-to-severe diseaseAssociated with accelerated photodamage and increased risk of malignancy; will not treat PsAMethotrexateModerate-to-severe diseaseMost widely used systemic treatment; inexpensive; pregnancy category XCyclosporinePsoriasis flaresUsed as a bridging agent during induction of other maintenance agents or for flaresAcitretinModerate-to-severe diseaseLow toxicity and no immunosuppression; can be used in patients with infection, malignancy, or HIV; need to monitor LFTs and triglycerides; contraindicated if considering pregnancy Biologic Agents(infliximab, etanercept, adalimumab, ustekinumab, secukinumab, tofacitinib, apremilast)Moderate-to-severe diseaseMay be used as first-line systemic agent depending on comorbidities and other considerations; highly efficacious; expensive

Menter A, et al.

J Am

Acad

Dermatol

. 2011;65:137-174.

Slide32

Treatment Considerations

Age

Pregnancy/lactation (current or future)

Patient/family medical history

Malignancies

Multiple sclerosis or CHF

Inflammatory bowel disease

Depression or suicide

Chronic infections

Other autoimmune diseases (ie, lupus)

Exposure to fungus or TB

History of HCV, HBV, HIV or high risk behavior

Social – alcohol consumption

Slide33

Psoriasis Treatment Algorithm

Psoriasis

+

PsA

Anti-TNF +/- MTX*

Extent of disease

TopicalsTargeted phototherapy

UVB/PUVA SystemicBiologic

Effective

Not Effective†

Mild

(limited)

No

Moderate/Severe

(extensive)

Yes

*Patients with nondeforming

PsA

without any radiographic changes, loss of range of motion, or interference with tasks of daily living should not automatically be treated with tumor necrosis factor (TNF ) inhibitors. It would be reasonable to treat these patients with a nonsteroidal anti-inflammatory agent or to consult a rheumatologist for therapeutic options. †Patients with limited skin disease should not automatically be treated with systemic treatment if they do not improve, because treatment with systemic therapy may carry more risk than the disease itself.

Adapted by Lilian McVey from Menter A, et al.

J Am

Acad

Dermatol

. 2008;58(5):826-850. Used with permission.

Slide34

Treatment of Mild-to-Moderate Psoriasis

Topical therapyCorticosteroids, vitamin D derivatives, tazarotene, anthralin, tacrolimus, pimecrolimus, newer tar formulationsMust be prescribed appropriately and used consistently for weeks to months for clinical improvementPotential AEsCutaneous atrophyTelangiectasiasHypothalamic-pituitary axis suppression

Stein Gold LF.

Semin

Cutan

Med Surg

. 2016;35(2

Suppl

2):S36-S44.

Koyama G, et al.

Int

J

Pharm

Compd

. 2015;19(5):357-365.

Slide35

Treatment of Mild-to-Moderate Psoriasis

Topical therapy (cont’d)Primary limitation is medication adherenceStrategies to optimize adherence:Consider dosage/schedule, choice of vehicleFixed-combination gels, foamsAddress patient preference about treatmentAddress concerns about treatment-related toxicitiesManage patient expectationsAssess patient response and know when to refer!Up to 80% of psoriasis patients receive no treatment or only topical therapy

Stein Gold LF.

Semin

Cutan

Med Surg

. 2016;35(2

Suppl

2):S36-S44.

Lebwohl

MG, et al.

Am J

Clin

Dermatol

. 2016;17(1):87-97.

Slide36

Treatment of Moderate-to-Severe Psoriasis

Refer to dermatologyPrimary care:Emphasize need for long-term follow-up and adherence to prescribed therapyEncourage lifestyle changesSmoking cessationDecreased alcohol consumptionHealthy diet and increased physical activityMonitor for AEsConsider early screening/intervention for CVD and metabolic disease

TreatmentPotential AEsPhototherapySquamous cell carcinoma, photoagingMethotrexateHepatotoxicity, bone marrow suppression, pneumonitisCyclosporinImpaired renal function, hypertension, lymphoma, cutaneous malignanciesAcitretinMucocutaneous side effects, dyslipidemiaBiologicsTuberculosis, and latent infections, hepatitis, CNS complications, cytopenia, multiple sclerosis, CHF

Aldredge

LM, et al.

J

Dermatol

Nurses Assoc

. 2016;8(1):14-26.

Menter

A, et al.

J Am

Acad

Dermatol

. 2008;58(5):826-850.

Slide37

Treatment of PsA

Treatment is guided by disease severity and symptoms

Treat to target (T2T) approach

Comorbidities may limit options (diabetes, metabolic syndrome, fatty liver, CAD)

Screening

CV risk factors (BP, lipids, smoking)

Weight loss counseling

Ultrasound of liver with elevated LFTs

Hepatitis screening

Tuberculosis screening –

quantiferon

gold TB is standard (or PPD skin test)

Vaccinations

Slide38

Treatment of PsA

NSAIDs

Intra-articular injections

Nonbiologic DMARDsmethotrexate, sulfasalazine, leflunomide, cyclosporin,

Biologic DMARDsanti-TNF, PDE4 inhibitors, anti-IL-12/23, anti-IL-17A

Adapted by Lilian McVey from

Gossec L, et al. Clin Exp Rheumatol. 2015;5 (Suppl 93):S73-S77. Used with permission.

Will not affect plaque psoriasis

Can also treat

plaque psoriasis

Slide39

Biologic Agents for Psoriasis/PsA

DrugTargetFDA-Approved for PsoriasisFDA-Approved for PsAEtanerceptTNF-receptorXXInfliximabTNF-alphaXXAdalimumabTNF-alphaXXUstekinumabAnti-IL-12/-23XXBrodalumabIL-17 receptorXIxekizumabIL-17AXSecukinumabIL-17AXXApremilastPhosphodiesterase 4 (PDE4)XXTofacitinibJanus Kinase (JAK-STAT pathway)XGolimumabTNF-alphaXCertolizumabTNF-alphaX

Alwan

W, Nestle FO.

Clin

Exp

Rheumatol

. 2015;33(5

Suppl

93):S2-S6.

Slide40

Biologic Agents in PsA

Benefits

Induce a durable long-term response56% improvement in tender joint counts70% improvement in swollen joint counts64% improvement in CRP level36% improvement in overall disease activity score (DAS) Improve Health Assessment Questionnaire (HAQ) scoresLong-term safety confirmed

Drawbacks

Potential AEsInjection site reactionsSerious infectionsPossible association with increase of some malignanciesLack of sustained response to TNF inhibitors in some PsA patientsIntravenous dosing of some medicationsCost

Coates LC, et al.

Ann Rheum Dis

. 2008;67(5):717-719.

Cawson

MR, et al.

BMC

Musculoskelet

Disord

. 2014;15:26.

Bissonnette

R, et al.

J

Cutan

Med Surg

. 2009;13(

Suppl

2):S67-S76.

Slide41

Treatment of PsA

Mild arthritisNSAIDsModerately severe arthritis or resistant to NSAIDMethotrexateLeflunomideApremilastSevere peripheral arthritis/adverse prognosisTNF inhibitorEtanerceptInfliximabAdalimumabGolimumabCertolizumab pegolOther biologic DMARDsSecukinumab Ustekinumab

Axial diseaseNSAIDsBiologic DMARDEnthesitisNSAIDsBiologic DMARDDactylitisNSAIDsDMARD

.

Slide42

Stay Tuned

American College of Rheumatology and the National Psoriasis Foundation Guideline for the Management of Psoriatic Arthritis

Anticipated completion 2018

Slide43

Monitoring

National Psoriasis Foundation (NPF) treatment targets for plaque psoriasisAcceptable: Either BSA ≤3% or BSA improvement ≥75% from baseline at 3 months after treatment initiationTarget: BSA ≤1% at 3 months after treatment initiationMonitor at least every 3 to 6 months during maintenance therapyReassess if skin symptoms or arthritis not under control

Armstrong

AW, et al

.

J Am

Acad

Dermatol

.

2017;76(2):290-298.

Slide44

Comorbidities Established in Psoriasis and PsA

Cardiovascular disease (CVD)Metabolic syndrome ObesityDyslipidemiaDiabetes

Mood disordersInflammatory bowel diseaseMalignancyUveitisAlcohol and addictive behaviors

Abuaara

K, et al.

Br J

Dermatol

. 2010;163(3):586-592; Armstrong AW, et al.

J

Hypertens

. 2013;31:433-442; discussion 442-443;

Azfar

RS, et al.

Arch

Dermatol

. 2012;148(9):995-1000;

Gelfand

JM, et al.

JAMA

. 2006;296(14):17351-741;

Gelfand

JM, et al.

J Invest

Dermatol

. 2006;126(10):2194-2201; Kurd SK, et al.

Arch

Derm

. 2010;146:891-895;

Langan

SM, et al.

J Invest

Derm

. 2012;132(3 Pt 1):556-562; Li W, et al.

Am J

Epidemiol

. 2012;175(5):402-413; Ma C, et al.

Br J

Dermatol

. 2013;168(3):486-495; Mehta NN, et al.

Eur

Heart J

. 2010;31(8):1000-1006;

Najarian

DJ, et al.

J Am

Acad

Dermatol

. 2003;48(6):805-821;

Yeung

H, et al.

JAMA

Derm

. 2013;149(10):1173-1179.

Slide45

Emerging Comorbidities

Callis

Duffin

K, et al.

J Am

Acad

Dermatol

. 2009;60(4):604-608;

Wakkee

M, et al.

J Am

Acad

Dermatol

. 2011;65(6):1135-1144; Van der

Voort

ET, et al.

J Am

Acad

Dermatol

. 2014;70:517-524; Yeung H, et al.

JAMA

Derm

. 2013;149(10):1173-1179; Yang YW, et al.

Br J

Derm

. 2011;165(5):1037-1043.

Slide46

Risk of Cardiometabolic Disease in Patients with More Severe Psoriasis

Clinical significance:Increased risk of MI, stroke, CV death, and diabetes5 years shorter life expectancy10-year risk of major CV event attributable to psoriasis = 6%Risk of CV disease in patients with severe psoriasis similar to risk conferred by diabetesPatients treated for severe psoriasis are 30 times more likely to experience MACE (attributable to psoriasis) than to develop a melanoma

MI = myocardial infarction, MACE = major adverse cardiac events, RR = relative risk.

1.

Abuaara

K, et al.

Br. J.

Dermatol

. 2010;163(3):586-592; 2.

Gelfand

JM, et al.

JAMA

. 2006;296(14):1735-1741.

3.

Gelfand

JM, et al.

J Invest

Derm

. 2009;129(10):2411-2418; 4. Mehta NN, et al.

Eur

Heart J

. 2010;31(8):1000-1006.

5. Mehta NN, et al.

Am J Med

. 2011;124(8):775.e1-6. 6.

Azfar

R, et al.

Arch

Derm

. 2012;148(9):995-1000.

Slide47

Cardiovascular Comorbidity in PsA

PsA patientsIR/1000 PYsNon-PsA patients IR/1000 PYsRates of incident CVD – All12.89.6Rates of MACE4.63.5

Rates of CVD and MACE are higher in patients with PsA compared to those without PsA

IR = incidence rate, PY = person-years.

Li L, et al.

J

Clin

Rheumatol

. 2015;21(8):405-410.

Slide48

Case Study28-year-old female nurse being followed in rheumatology clinic for fibromyalgia diagnosed 5 years prior presents c/o worsening back and hand pain over the last several months.

HistoryInflammatory back painSomewhat responsive to NSAIDs, h/o gastric ulcerNo h/o psoriatic diseasePhysical examScalp psoriasisDactylitis right second finger

Laboratory

ANA 1:40

Neg RF, anti-CCP

ESR 35, CRP 7

HLAB27 positive

Slide49

Case Study

Diagnosed with psoriasis and

PsA

after review of labs and films

Treatment considerations

Negative hepatitis and TB screening

History of gastric ulcer

Considering pregnancy in the next year

Options

Methotrexate

Unable to tolerate: GI distress and hair loss

TNF inhibitor

Etanercept

At 3-month follow-up,

dactylitis

absent, scalp psoriasis clear, AM stiffness 30 minutes, back pain improved though not gone

Slide50

Case Study

Two years later, stopped etanercept with pregnancy confirmation

Back pain worse during pregnancy

At 2 months postpartum

Scalp psoriasis worse, patches on elbows and hands

Joint pain and stiffness in hands and knees

Difficulty with ADLs

Resumed etanercept with reduction in symptoms

Slide51

Primary Care Pearls

Take a good history from the patient

Complete a thorough skin examination

Assess for joint signs and symptoms

Monitor patients for comorbidities sooner than the general population

Monitor for side effects and treatment complications

Slide52

Primary Care Pearls

Assess for adherence to therapy

Ensure all a

ge-appropriate screening

Assess for

QoL

and ADLs

Assess for psychosocial

Patients on biologics or immunosuppressants

Do not give live vaccines

Notify specialist (dermatology or rheumatology) if patient develops

Serious signs or symptoms of infection

Change in medical condition

Slide53

Please complete the

post-activity survey and the activity evaluation.

Slide54

Q&A