Remote Teams Offer Chance to Improve
Difficult-to-Treat PsA

Pat Kelly

July 17, 2023

DUBLIN, Ireland — A multidisciplinary team (MDT) approach using videoconferencing to discuss the management of patients with difficult-to-treat psoriatic arthritis (PsA) can help rheumatologists to improve outcomes, according to presenters at the annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).

In the same session at the meeting, GRAPPA also announced a new initiative to define difficult-to-treat PsA.

Deepak Jadon, MB BCh, PhD, a rheumatologist with Cambridge University Hospitals NHS Foundation Trust, United Kingdom, described his experience of running a clinic for patients with difficult-to-treat PsA in the East of England, covering a catchment area of approximately 6 million people between six and seven hospitals. He discussed how the MDT in his region operates to discuss the management of such patients, whose treatment options may also have indications for comorbidities such as inflammatory bowel disease or uveitis, or have complicating factors such as metabolic syndrome.

"You have to have an interested and engaged colleague to form that collaboration," Jadon said. "If you are working in isolation, without your colleagues in the same building, that becomes harder. We have been running remote multispecialty meetings without the patient being present, and I have had the good fortune of having medical students brought into our practice. We discussed approximately 220 patients, initially in our psoriasis-spondyloarthritis MDT and subsequently in our inflammatory bowel disease-spondyloarthritis MDT."

There are also MDTs with hepatologist colleagues carried out on an ad hoc basis to discuss patients with nonalcoholic fatty liver disease, as well as patients with hepatitis or a transplanted liver, who have psoriatic disease.

This difficult-to-treat cohort is discussed in MDT meetings conducted on Zoom. At MDT meetings, carried out with frequencies ranging from monthly to bimonthly, Jadon said there would be two dermatologists, two rheumatologists, 1-4 dermatology and rheumatology trainees and fellows, 1-4 specialist nurses, 1-3 research nurses, and one biologics pharmacist. They record the meetings and discuss anywhere from 4 to 18 patients, reviewing items in their electronic medical record, calling or writing patients and/or their primary care clinician as needed. They take about an hour to meet, with a half hour of prep time and another 1.5 hours to undertake necessary actions.

"Generally, the question is, how can we change treatment to best cover the domains of disease?" Jadon said. "Progressively, more patients are being put onto biologics as a result of these conversations, and I do feel that it has helped our patients and us to consolidate their management plan. Naturally, as all clinicians do, we doubt ourselves and wonder if we are missing something. Is there an aspect of the disease [being missed]? Is there a treatment that I haven’t been using? [The meetings have] been reassuring in that regard. I also learn from my colleagues who have earlier access to treatments, especially in dermatology."

In a small number of patients, some combinations of advanced therapies, such as combining a Janus kinase inhibitor with a biologic, have been used as a result of these collaborations, "and to discuss this in an MDT has been reassuring, including from a medico-legal perspective," Jadon said. "One of the main things we found to be useful is having a brief referral pro forma. Usually, by the time patients reach this forum, they have used a lot of treatments, and it can be difficult to remember that on the spot. It is also important to focus on what the actual question is," he continued. "Naturally, in these discussions, where you talk about the complexities and various facets of disease, you can get a bit lost and sometimes you actually don’t address the original question."

He also said it has been very beneficial to use screen sharing in the remote MDTs so that different disciplines can review images together, such as with radiology colleagues. "There are varying skill sets among our colleagues, especially in radiology, and it has been quite nice to review their peripheral imaging, their axial imaging, laboratory markers, and skin lesions together."

New GRAPPA Project to Provide Clarity

A new GRAPPA project has been devised to help physicians identify and define difficult-to-treat and difficult-to-manage PsA in order to help physicians to categorize and treat these patients.

"We have a growing treatment armamentarium…but we still do not reach all the patients that we would like to," said Fabian Proft, MD, of Charité University Medicine, Berlin, Germany. "We set our targets, but we see in the real world that we are only reaching them in 40% or 50% of our patients. So, we need to do better, and in order to do better, we need to understand better."

"We should not only make a definition of difficult-to-treat PsA, which is nonresponse to treatment with objective signs of inflammation, but also we need to address and acknowledge difficult-to-manage [patients]," Proft said. "We should not stop as soon as we come up with a definition. This will be a working definition and will need to be validated."

The speakers report no relevant financial relationships.

Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) 2023 Annual Meeting: No Abstract. Presented July 15, 2023.

Pat Kelly is a medical journalist in Dublin, Ireland.

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