This transcript has been edited for clarity.
Steve Feldman, MD: Welcome to Medscape InDiscussion. I'm host Dr Steve Feldman. Today, we're talking about the comorbidities of patients with psoriasis and what to do about them. We'll cover how to screen psoriasis patients for arthritis, some of the exciting research going on regarding cardiovascular effects of psoriasis inflammation, and what we need to do to screen for other comorbidities in psoriasis patients. It may not be what you expect. Anyway, we'll get to that shortly.
Let me introduce our guest. She's extraordinary. An associate professor of medicine and epidemiology at the University of Pennsylvania, she specializes in psoriatic and other forms of inflammatory arthritis, she is director of the Penn Psoriatic Arthritis and Spondyloarthropathies Program, and she is deputy director of the Center for Clinical Epidemiology & Biostatistics. I'm so happy to welcome Dr Alexis Ogdie-Beatty. Thank you so much.
Alexis Ogdie-Beatty, MD: Thanks so much for having me today.
Feldman Alexis, you're doing it all. Clinic, research — how do you keep it all in balance? Or, should I ask, do you have work-life balance?
Ogdie-Beatty: I know. Is balance possible? For me, balance changes on a regular basis, like every couple of weeks or every couple of months. Setting the tone for how the next week will be is something I try to do over the weekend, and I try to get all the workouts in so I can have a fresh mind every day. That's my approach. I'm not sure it always works, but I try.
Feldman: Let's start with comorbidities of psoriasis. The most common one is psoriatic arthritis. I want to know basic stuff like what screening questions I should be asking patients.
Ogdie-Beatty: That's a great question. The interesting thing is that dermatologists often don't feel comfortable with joints, but they are the ones picking up [joint disease] most of the time. A lot of it is very visual, so dermatologists could be very good at assessing joints with a little training. But what kinds of questions should you be asking your patients? One question is, “Have you had joint pain or joint swelling?” Joint pain is pretty common — many people have joint pain — but joint swelling is less common. If you have joint swelling, that's a reason to raise an eyebrow and say, “Maybe this person should be seeing Rheumatology.”
Also, a lot of people with psoriatic arthritis have morning stiffness; this is one of the cardinal signs of inflammatory diseases. Typically, when a person wakes up in the morning, you feel like it's really hard to move. For patients with osteoarthritis, they experience the same thing, but it tends to go away within a few minutes — maybe 10 to 15 minutes. But in inflammatory arthritis, it tends to last for 30, 45 minutes or more — even several hours for some people. If you hear that, it's another symptom you might refer patients to Rheumatology for.
Feldman: OK, so my stiffness is probably osteoarthritis. That's good to know. What physical exam should I do for patients when they are having joint pain?
Ogdie-Beatty: Physical examination in rheumatology takes a couple of years as a fellow to get comfortable with. But what dermatologists are really good at is symmetry. If you have a joint in a patient you think is swollen, you look at the other side to see if one joint is different from the other. The helpful thing about psoriatic arthritis is that it tends to be asymmetric. We would expect to see that the patient has swelling in one joint, but not so much in the other.
The other thing is to push on the joint. Often, there's some “squishiness” involved in a swollen joint, or you might get a little fluctuation. Fluctuation in the knee, and potentially in other joints, is kind of a squishy feeling. If it feels bony or hard, that's more likely osteoarthritis or long-standing joint damage, but the squishing really speaks to the active swelling.
Feldman: I'm glad you didn't tell me what the last rheumatologist told me, which was, “Steve, if they're having joint symptoms, do a complete musculoskeletal exam, including a range of motion and gait.” And I'm like, “No, I don't think I'm going to do that.”
Ogdie-Beatty: You can send them to us for that.
Feldman: If the physical exam these patients should have is a complete musculoskeletal exam, then why do I need to do anything? I just need to make a referral to rheumatology.
Ogdie-Beatty: I guess the one problem with that is, if they have joint symptoms — and we are obviously very limited because there are fewer rheumatologists than dermatologists, so we have trouble seeing everybody — anything you can do to help us pinhole who should get through the door faster than someone else is helpful.
Feldman: For inflammatory arthritis, you get them in quicker because you can help those people. If they've got fibromyalgia, you're not as excited about seeing them.
Ogdie-Beatty: At some point, they probably should see us. Some of my colleagues would not necessarily agree to that, but everybody should see a rheumatologist once with this diagnosis, just to help rule out that the [joint symptoms aren't] something else.
Feldman: That's interesting. So, this means I do have to send everybody with joint pain to you, but I don't have to rush them in. I know if we send them to you, you'll take care of their arthritis and treat them appropriately. But are there any psoriatic arthritis treatments I should be doing, or should I be modifying my psoriasis treatment if my patients have joint pain?
Ogdie-Beatty: Sometimes dermatologists are in the best position to get treatment started while patients are waiting to come into Rheumatology, especially if it's going to be a long wait. The one critical thing is whether or not patients have axial disease. If they have inflammatory arthritis, you can probably pick any of your treatments for psoriasis that are systemic treatments, especially the ones already approved for psoriatic arthritis, which, again, are most of them. On the other hand, if patients have axial disease, it modifies the types of treatments that are going to be helpful. For example, it basically pinholes your treatment to a TNF inhibitor or an interleukin (IL)-17 inhibitor. The other therapies don't really have great data for axial disease.
Feldman: That raises two points, the first of which is: Not having data to show that it's effective is different from having data to show that it's ineffective.
Ogdie-Beatty: Yes, and it becomes very confusing when you talk about that. Let's talk about the IL-23 inhibitors for a second. There are data in ankylosing spondylitis, which is closely related to psoriatic arthritis spine disease. For example, risankizumab and ustekinumab have great negative clinical trials, but they didn't really help the axial disease. Guselkumab and ustekinumab have shown in their psoriatic arthritis trials that they improve a patient-reported outcome called the BASDAI (Bath Ankylosing Spondylitis Disease Activity Index), which is supposedly an ankylosing spondylitis measure. There's only one question in the whole survey about spine disease, and it shows that the disease improves. But what I will tell you is that it does not necessarily translate to axial disease improvement, and that our axial spondyloarthritis, or ankylosing spondylitis, trials are actually a better marker for that. Although I am hedging a little and saying we don't have data, we actually have data in ankylosing spondylitis that say these drugs don't work. So, there's a burden of proof on these drugs to prove they actually work in axial spondyloarthritis, and those trials are ongoing or getting started.
Feldman: That takes me back to the screening questions because we didn't ask about back pain. I'm thinking that if I ask patients, “Are you having any joint pain, joint stiffness, or back pain?” it may not be the most specific, but it'll be sensitive.
Ogdie-Beatty: The reason I didn't bring that up initially is that it is really kind of tricky; a lot of people have back pain. In fact, 70% of the people you ask have back pain at some point. And then back stiffness, which is a little bit more specific, is not always [useful] because it’s not that sensitive [as a symptom or sign]. One of the things we do often as rheumatologists, in the setting of back pain, is to get x-rays of the sacroiliac joints and not the lumbar spine, which is where most primary care doctors get x-rays. The lumbar spine doesn't tell you anything. It is the sacroiliac joints. And if there's something on the sacroiliac joints, it suggests axial disease associated with psoriasis. Dr Joel Gelfand, a collaborator at Penn, will often send those [sacroiliac] x-rays to us [in rheumatology] in advance because he's an advanced dermatologist with musculoskeletal training. If there is an abnormality, he might get us involved before selecting a therapy. That's something to think about, although it's hard to recommend all dermatologists do this because [sacroiliac x-ray results] are not quite so clear, even sometimes for rheumatologists.
Feldman: That brings up referring. Do you have any specific guidelines on whom you want referred?
Ogdie-Beatty: We want to see patients who have active joint swelling, or those who are really uncomfortable with axial or back pain symptoms that affect their activities of daily living. But with joint swelling, we want to see them ASAP. For patients with dactylitis, which is swelling of the entire digit like a big sausage, we want to see them ASAP to help sort things out and get treatment started. These patients may have disease that is more likely to progress quickly. Those are the first people to get in the door. And then if you're wondering: Is this osteoarthritis? Is this psoriatic arthritis? Do we need help deciding on treatment? These are the other people we probably should see sooner.
Feldman: What lab tests would you like to have when you're seeing the patient?
Ogdie-Beatty: We've worked this out with our dermatologist and have our sets: a complete metabolic panel and complete blood cell count, so we have baselines; and C-reactive protein, which isn't that helpful in picking who has a disease vs who doesn't but is helpful to follow if levels are elevated. And then QuantiFERON-TB Gold because we're probably going to be starting a therapy requiring it. You could also consider hepatitis B and hepatitis C serologic tests — the usual tests before starting a biologic therapy.
Feldman: That's excellent. I think we've covered psoriatic arthritis from beginning to end. Let's talk now about Joel Gelfand's work on cardiovascular comorbidity. You have all been doing amazing work on that at the [University of Pennsylvania]. I think that’s some of the hottest research going on in the world of dermatology.
Ogdie-Beatty: Yeah, we have a new study we're getting off the ground to look at how to make this practical for screening in clinical practice.
Feldman: It sounds like you think there should be some screening?
Ogdie-Beatty: I do think there should be screening. I screen almost all my patients as a part of my plan for every patient. I can remove it if I want, but it's always there so I think about it. If it's in my template, then I know at least I'll think about it and ask about when a patient had their lipid levels tested or if they had an A1c screening. And I add those in with the labs once a year, if a patient has not had those done with a primary care physician.
Feldman: You're not recommending additional screening beyond what would be standard and age appropriate for people?
Ogdie-Beatty: I try to get lipids and A1c for everybody at some point, but I don't necessarily have to get them if the primary care provider has done them. I will say that 30%-50% of my patients aren't really seeing a primary care physician, and I don't know what that's like in dermatology. But we have a lot of patients who think the specialist is good enough. If someone has a good primary care doctor where I know they're doing the follow up, I say defer to primary care.
Feldman: I get on my “high horse” when I hear people tell me, “Well, there's an elevated risk of something we need to screen for.” I wonder, unless there's a strong reason to screen, should we really be screening? I'm old. They check my cholesterol. It's high, and they say, “Go on a statin. You'll reduce your risk by 30%.” That sounds like a lot until you realize my baseline risk for an event over the next 10 or 20 years is about 7%, and a 30% reduction of 7% is down to 5%. So, I take a pill every day to go from a risk of 7% to 5%. Is that clinically meaningful?
Ogdie-Beatty: Well, first of all, 7% would be on the border where you may or may not actually [recommend a statin]. It's usually the people who have a little higher risk — 10% or more in the next 5 years — that you're going to want to start on a statin. We're thinking about the whole patient sitting in front of us and we're treating one disease. [Psoriatic disease] is closely linked with a bunch of other things, including obesity and metabolic disease. I know that if I can get the patient to lose weight, I could get them to respond better to their therapy. Their disease would be less impactful. They'd have better quality of life. There are so many other benefits [to losing weight].
And then for the lipids, it's an opportunity for engagement on this topic. Metabolic disease has significant impact on quality of life. Not to mention, if you had a heart attack, that's going to absolutely change your life. It's how bad the outcome is if you have that outcome. Of course, it is rare. But if you think about COVID vaccination, we're pushing that hard core, and the risk for death from COVID is lower than what we're talking about for cardiovascular disease, the number-one killer. It's important to address it and to have an entry for the conversation. We might not always be the one that starts this; we're often not going to be the people starting the statin, but we're laying a foundation that it's important for overall health. The disease I'm treating is one piece of overall health, which gets people through the day and through the next 10 years, but we have an opportunity as patient care providers to help patients think about [overall health over time].
Feldman: I was reading that you've started to incorporate behavioral economic tools into your research. I would love to hear more about that.
Ogdie-Beatty: One of the things we've been focusing on is this holistic, healthy lifestyle piece of psoriatic disease. The reason is that most of our patients are obese, so we deal with a patient population that is more obese than patients with psoriasis, more obese than patients with rheumatoid arthritis, and certainly more obese than the general population. We know that obesity has significant impacts on patient function and how well their drugs work. We end up cycling through drugs with some of these patients just because we can't get their disease under control.
We wanted to think about how we get these patients better. We know that lifestyle interventions are things people do not line up for. No one really wants to go on a diet. No one really wants to work on weight loss. They just want it to happen. And they'd love to have a drug that magically makes it all better if you just give it to them. So, how do you make lifestyle interventions easier? This is where behavioral economics comes in.
There are different strategies to make things easier. Some of these are changing the status quo. Even as prescribers, we have a status quo. We pick the first [medication] on the list when we put in a medication order. But that first one on the list may be a brand name medication, and if we ordered a generic, we'd be saving the whole health system some money. If you reverse the order of the [medication options], people will still tend to pick the first one. So, you can decrease costs to the whole health system by changing the status quo.
Feldman: You might even have the first one prechecked so [prescribers] would have to uncheck it to choose something more expensive.
Ogdie-Beatty: Exactly. Defaults are another way to do that. With all the competing things that people are thinking about on a day-to-day basis, especially now, it's hard to make any of these things stick. Anything we can do to make it easier is helpful.
Feldman: Yes, and when you say, "things people are thinking about," I [realize] we do a lot of stuff without thinking.
Ogdie-Beatty: One of the main concepts behind behavioral economics is that there are two parts of the brain. There's the automatic emotional part like what you use to drive to work every day; you don't think about all the things you see on your way to work because that's just your route. You just go. There's also an analytical side, but it's hard to use the analytical side. We have to force ourselves [to use the analytical side]. Anything you can do to signpost along the way in the more emotional automaticity [realm] can help a lot with changing things. That's where changing the default or changing the status quo can really help.
Feldman: Outstanding. As we wrap up, tell me one thing you really want to pass on to listeners before I let you go.
Ogdie-Beatty: Dermatologists should ask their patients questions about psoriatic arthritis or have a handout to let them know that psoriatic arthritis can be associated with psoriasis, so patients are aware of it. They can go to their primary care doctor or seek out a rheumatologist. The same thing works with cardiovascular disease; if patients know there's an association — even if you're not the one sending the lipids — they can go ask their primary care doctor about it. Having these things on patients’ minds, or at least helping them understand the link, is helpful for improving outcomes.
Feldman: I will recommit myself. Hopefully, listeners will, too. When we see patients with psoriasis, ask them if they're having psoriatic arthritis [symptoms]. Ask about joint pain, stiffness, back pain, and swelling, and make sure they're aware of cardiovascular disease. Maybe if they keep hearing the message, they'll live a healthier lifestyle.
Alexis, thank you so much for your time today. It's really a pleasure seeing you and talking with you.
Ogdie-Beatty: Thanks so much for having me today. It's great talking to you, too.
Axial Involvement in Psoriatic Arthritis Cohort (AXIS): The Protocol of a Joint Project of the Assessment of SpondyloArthritis International Society (ASAS) and the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)
Efficacy and Safety of Ustekinumab in Psoriatic Arthritis Patients With Peripheral Arthritis and Physician-Reported Spondylitis: Post-hoc Analyses From Two Phase III, Multicenter, Double-blind, Placebo-Controlled Studies (PSUMMIT-1/PSUMMIT-2)
Effectiveness, Costs and Cost-effectiveness of Chiropractic Care and Physiotherapy Compared With Information and Advice in the Treatment of Non-specific Chronic Low Back Pain: Study Protocol for a Randomised Controlled Trial
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Cite this: How to Quickly Spot and Manage Psoriasis Comorbidities - Medscape - Apr 05, 2022.