Psoriatic Arthritis Podcast

How to Integrate Wellness into Psoriatic Arthritis Care

Elaine Husni, MD, MPH; Robert Saper, MD, MPH; Leonard Calabrese, DO


December 15, 2021

This transcript has been edited for clarity.

Elaine Husni, MD, MPH: Hello. I'm Dr Elaine Husni, I'm a rheumatologist at the Cleveland Clinic with a special interest in psoriatic arthritis care and I co-direct an interdisciplinary dermatology-rheumatology clinic here at the Cleveland Clinic. I want to welcome you all. I'm super-excited to chat with Dr Len Calabrese and Dr Rob Saper today. We are going to talk about wellness strategies and psoriatic arthritis. Dr Calabrese is the vice chair of the Department of Rheumatic and Immunologic Diseases, as well as a chair in the section of clinical immunology. He's lectured nationally and internationally on HIV, immunology, and rheumatology topics. And we'll hear from him about his wellness strategies. Dr Rob Saper is the chair of the Department of Wellness and Preventive Medicine at the Cleveland Clinic. We are so lucky to have him. We recruited him from Boston Medical Center, where he was the founder of the program of Integrative Medicine and Health Disparities at Boston Medical Center. Welcome to the both of you.

Leonard Calabrese, DO: Great to be here.

Robert Saper, MD, MPH: Great. Thank you.

Husni: Welcome. I'd love to start off with a case. I have a middle-aged female who was diagnosed with psoriatic arthritis. She has had psoriasis since her college years but only used topical treatments. It wasn't until after the birth of her first child that she started developing some worsening nail changes and dactylitis — sausage toes and sausage fingers. She elected not to treat the psoriatic arthritis because she was breastfeeding at the time.

After 4 or 5 months, she stopped breastfeeding and because of ongoing active psoriatic arthritis, she was started on methotrexate. Methotrexate really improved her morning stiffness and cleared her skin to the point where she no longer needed topicals, but she started having a lot of gastrointestinal (GI) upset and fatigue with the methotrexate. She felt that it was preventing her from taking care of her children.

A friend at church said that her psoriasis improved with a gluten-free diet and urged her to stop the methotrexate and try the diet for a couple of months. So, she came to my office and asked for some direction as to what she should do about stopping treatment or continuing treatment, and about her gluten-free diet treatment. This is a fairly common scenario that I see in my practice and it puts wellness strategies right in the forefront because I'm asked about them right away. I would love to hear from you, Len. Have you had any similar experiences? How do you coach a patient through something like this?

Calabrese: Yeah. It is very common and it really sets up so many of the critical issues in confronting patients with rheumatic and immunologic diseases. On the one hand, the patient has active disease and has been treated with fairly standard therapy and clearly needs an escalation of therapy to stop this disease, which is eroding bone and is, over time, going to lead to significant complications.

On the other hand, the patient is expressing not complaints but concerns that there may be other alternatives out there that don't involve the therapies and possible side effects that she's been experiencing. I look at this as an if/then question. So my goal in talking to a patient like that is to address both their complaints and their concerns and emphasize that we have an extraordinary armamentarium for their disease. Plus, we have an array of interventions that can strengthen their immune health and work in a complementary fashion to achieve their own goals and suppress the disease at the same time.

One of the great fears among practitioners in immunologic diseases across all specialties is that if a patient engages in some type of wellness behavior that they will jettison their targeted or biologic therapy or specific therapy. And our message is one of complementary therapies.

Husni: I like that — complaints vs concerns. So, Rob, I know that you may not take care of as many autoimmune patients, but I know you have some. And when they ask you very specifically about a diet or a supplement, how do you go about starting that conversation and moving them along?

Saper: This is a terrific case, and it's prototypical for a number of reasons, Many people receive recommendations from family or friends to try things, like this patient did. There is also this concern about patients being advised to stop a medicine and instead, as in this case, start a diet. It's important for us as clinicians not to see this as an either/or, either the methotrexate or the gluten-free diet, but really to see it as both. When we hear our patient asking these questions, we need to frame it as a strength. They are looking to get better. They want to know what's in their control. And we want to leverage that and empower them and not diminish them. So when they're interested in an intervention where it is not unsafe and there may be some efficacy, such as a gluten-free diet, and they're motivated to do it, and it's not going to cost them the bank to do it, then I would encourage them to do it. And, like Len said, work with them and talk with them about the other options that are there. And remember, as physicians, patients' concerns about side effects — like with the methotrexate — can be challenging for us. Sometimes we feel a little defensive because those are our tools, but they're real and we have to empathize. And the more that we empathize with their condition, with their concerns, then hopefully the more they're likely going to be able to continue with our next recommendation of a medication. The majority of patients want to have both physician care with medications and lifestyle approaches. Is there a minority that wants to do either/or? Sure. But really, data show that the majority want to integrate the two.

Calabrese: That notion of empowerment is incredible. And my message for patients with immune-mediated inflammatory diseases is that I try to explain the exposome — that our immune systems are affected by all types of external factors: how we eat, how we sleep, how we exercise, how we handle our stress, the chemicals in our food, the pollution in the atmosphere, global warming, and beyond. And that there are certain things that are under our control, such as our behaviors, eating, sleeping, destressing, and exercising, that can empower our immune system and optimize them. And I think that's a very empowering message. I have an immune disease. My behavior affects my immune system. If I can buy into this — whether it's moving their diet from the standard American diet down toward a more vegetable-enriched, anti-inflammatory diet, great — getting a little more sleep, adding steps to your day, or giving them destressing strategies. Very empowering.

Husni: I love the way you expressed that: leveraging energy to empower wellness strategies.

We all have limited time with patients, and I would love to hear from each of you about how to really motivate patients for lifestyle changes and wellness with limited time. I'm also a bit overwhelmed by apps and referrals and what the out-of-pocket expense will be for my patients. So, I'd love some practical tips: What are the key drivers for communication of wellness strategies?

Saper: It's such an important question. I look at it as a pyramid with three levels. The first level is self-care. What are the strategies we can suggest to the patient that they can start today? It's not going to cost them anything or minimal, doesn't involve a referral or a clinician. And that's where I think the apps can play a role, and it is a dizzying array of commercial apps that are out there. However, data are emerging, for example, for Headspace, for Calm. Insight Timer is a free app, and Cleveland Clinic has developed a number of apps, such as Mindful Moments and Stress Free Now. These have evidence-based mindfulness activities, information about nutrition, and some workouts that are self-guided. The next level, and I think it's for the patient who has more morbidity, would be some kind of help, but not necessarily a clinician. So this could be a health coach or maybe joining a class at the YMCA, or the Jewish Community Center, or in one's church, or partnering with someone to get a buddy and come in together, or community programs like Weight Watchers, for example, for weight loss. And then that top tier is to refer to a clinician such as a lifestyle medicine clinician, integrative medicine clinician, or nutritionists, where individual and group visits can really do an immersion into this kind of work. And I think that's reserved for the patients for whom the disease is perhaps most severe, or their level of empowerment or self-efficacy is lower.

Husni: Yeah, I love that sort of team approach that I'm hearing about integrative wellness — very helpful to know. So, Len, we see these patients with immune-mediated diseases (IMIDs) like the one I presented. What is your construct? How do you go about implementing wellness strategies from day one?

Calabrese: Well, we've done this in an iterative fashion and in our offices. In the R.J. Fasenmyer Center, we have our little flat screen TVs up in all our rooms. And we have wellness messages about everything, from tai chi and responding to vaccines to zoster, to thoughts on eating less meat and more vegetables, to cues about general wellness. So it sets a tone.

The second thing is that every single patient that we see, we give our monograph, which we have been redoing for a decade, and it's called maintaining a healthy immune system. What you can do to help. It's about eating, sleeping, exercising and destressing, and it's available totally free. It's on the Cleveland Clinic website — Cleveland Clinic CME, under Rheumatology — it's at the RheumNow website and I encourage anybody to use it. So it gives them a 30-page document for them and their family. For those that want to go deeper — over and above these measures — then we're so fortunate to have outstanding practitioners and referral resources in Rob's wellness area. It is very caring. It is very collaborative. And when you have a practitioner that is practicing quality wellness medicine that you know that can work synergistically with you, then that would be at the top of my rung of how I would deal with patients.

Husni: So, as we end this podcast, I'd like to ask each of you: What are the first three ingredients that go into a successful wellness strategies recipe?

Saper: Number one: resources, like the excellent monograph that Len is describing where people can become educated, and then second, the environment that the healthcare system creates to bring about health and wellness. These images that Len is describing on the flat screen, the architecture makes such a big difference. It creates a healing environment. And then third, a group of clinicians who are well themselves, who pursue wellness, who are passionate about it.

Husni: Yes. Our own colleagues need to be well to produce wellness. So, Len, what are the first three ingredients that go into a successful wellness strategy recipe?

Calabrese: Wellness will not happen unless you empower people through knowledge; they have to buy in, they have to believe. Our immune system is under some control by our behaviors. That's an empowering message if patients know they have an immunologic disease. Second, providing evidence-based resources. And then finally, it's really listening to the patient. If we can communicate empathically with people and understand what their concerns are, I think we are much more likely to come up with a successful solution if we can step in their shoes even for those few minutes that we're with them.

Husni: Thank you so much for both your passion and your insight into wellness. It's been incredibly helpful and useful, and to take some of these very specific steps and ideas and caring for our patients with psoriatic arthritis. Thank you very much to the both of you.

Saper: Thank you.

Calabrese: Thank you.


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