Psoriatic Arthritis: Diagnosis and Treatment

WebMD Live Events Transcript

Psoriatic arthritis causes stiff, painful, and swollen joints, often in the hands, feet, knees, and ankles, along with psoriatic skin lesions. Often missed by patients and doctors who don't make the connection between joint pain and what is thought of as a skin disease, psoriatic arthritis is chronically undertreated. We discussed what you need to know about psoriatic arthritis when Mark Lebwohl, MD, was our guest on Aug. 31, 2004.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

This event was made possible through a grant from Amgen and Wyeth

MODERATOR:
Welcome back to WebMD Live, Dr. Lebwohl. What does psoriasis have to do with arthritis?

LEBWOHL:
A significant proportion of patients with psoriasis will develop a form of arthritis that has been called psoriatic arthritis. Approximately 30% of psoriasis patients develop psoriatic arthritis. If you look at published papers on this you'll find numbers as low as 5% developing it, but if you look harder, and by that I mean simply asking patients if any joints hurt, you'll find a higher proportion of patients with psoriatic arthritis.

There are several distinct forms of psoriatic arthritis. The most common form involves one or a few joints. Another form is virtually identical to rheumatoid arthritis. Less common forms are a form that involves primarily the spine, and that's called ankylosing spondylitis. Another very destructive form is called arthritis mutilans, and yet another uncommon type is involvement of the distal interphalangeal joints.

Certainly psoriasis is one of the autoimmune disorders. It seems a similar process as to what's going on in the skin is also going on in the joints. So for example, a chemical called TNF is elevated in the skin of plaques of psoriasis and is elevated in the joints of patients with psoriatic arthritis.

MODERATOR:
You are the chairman of the board of the National Psoriasis Foundation and this is Psoriasis Awareness Month. What activities is your organization doing to spread awareness?

LEBWOHL:
The Psoriasis Foundation has an extraordinary number of activities that are going on year round, but have been highlighted this month. A list of them can be obtained at www.psoriasis.org, or patients can call the Psoriasis Foundation at 1-800-723-9166. A tremendous amount of resources are directed at psoriasis research, psoriasis education (including dozens of publications), and patient advocacy.

Most recently, because of the high cost of biologic drugs, the Psoriasis Foundation has been heavily involved in advocating for patients with their insurance companies to enable them to obtain the best treatments available.

"Until recently, methotrexate was one of the more effective treatments we had for psoriatic arthritis. Most recently a new category of drugs, called TNF blockers, have proved to be dramatically effective for psoriatic arthritis."

MEMBER QUESTION:
I am a pediatrician with psoriasis since I was 6 or 7 years old, with swelling of two fingers in my hand and also two in my feet. I also have mild pain of my hip. What is the latest treatment for that?

LEBWOHL:
If symptoms of psoriatic arthritis are localized and mild, we usually start with NSAIDs, such as ibuprofen or naproxen. If symptoms are more severe, then we go to other treatments. Until recently, methotrexate was one of the more effective treatments we had for psoriatic arthritis. Most recently a new category of drugs, called TNF blockers, have proved to be dramatically effective for psoriatic arthritis.

MEMBER QUESTION:
How is it determined that the joint pain is psoriatic arthritis? Is all joint pain in someone with psoriasis caused by the psoriasis?

LEBWOHL:
Sometimes it is very simple to diagnose psoriatic arthritis, if, for example, a characteristic joint is affected, such as the DIP (the little joints at the end of the fingers). Other times it's difficult to differentiate what is causing the arthritis.

There are certain tests we have to resort to, to distinguish between rheumatoid and psoriatic arthritis. One of the blood tests we use is called the rheumatoid factor, which is usually positive in rheumatoid arthritis and usually negative in psoriatic arthritis.

MEMBER QUESTION:
If a person has psoriasis and takes PUVA treatments that cause psoriasis to go into remission and this person also has psoriatic arthritis, is there any chance of the arthritis clearing up also?

LEBWOHL:
Yes, in some patients PUVA will result in improvement in psoriatic arthritis, but not in everyone. I have seen dramatic improvement in psoriatic arthritis in individual patients following PUVA therapy. But some forms of psoriatic arthritis, such as arthritis of the spine, seldom improve following PUVA.

MEMBER QUESTION:
I know that Amevive has the ability to help with psoriasis, but can it help with the psoriatic arthritis, too? It seems that if the psoriasis is gone, so should the arthritis?

LEBWOHL:
There have been small studies in limited numbers of patients looking of the effect of Amevive (alefacept) for psoriatic arthritis, and these in fact have shown an improvement not only in psoriasis, but also in psoriatic arthritis.

MEMBER QUESTION:
If you have psoriasis of the face and scalp along with osteoarthritis, medicated at present with Celebrex only, would you consider Enbrel as a course of treatment? Thank you.

LEBWOHL:
Enbrel is not approved for osteoarthritis, but it is approved and dramatically effective for psoriatic arthritis.

MEMBER QUESTION:
I am on Enbrel and was diagnosed with strep throat. Is this a sign that this could be a recurring problem for me while on Enbrel (also on methotrexate)?

LEBWOHL:
Etanercept (Enbrel) and methotrexate do suppress the immune system and patients may be a little more prone to developing infections, but hopefully this is a one-time event, and hopefully you won't get many more infections.

MEMBER QUESTION:
I am on Enbrel and that has helped with the stiffness, but the skin condition has not improved. Any suggestions?

LEBWOHL:
The dose of entanercept (Enbrel) that is approved for skin psoriasis is higher than the dose approved for psoriatic arthritis. We usually start patients on 50 milligrams twice a week (four vials a week) for the first three months, when treating the skin.

MEMBER QUESTION:
My husband has psoriasis and psoriatic arthritis. He is taking 100 milligrams of Indocin per day and 15 milligrams of methotrexate per week. He has an appointment with his rheumatologist soon and is going to ask about going on Enbrel. Would that be a better medication to be on?

LEBWOHL:
As a rule, etanercept (Enbrel) is more effective and safer than methotrexate for psoriatic arthritis. It treats not only the pain of psoriatic arthritis, but also prevents joint destruction more effectively than methotrexate. Unfortunately, it is much more expensive.

MEMBER QUESTION:
What kinds of biologics are used for psoriasis and psoriatic arthritis?

LEBWOHL:
Four of the currently available biologics, alefacept, etanercept, infliximab and adalimumab, are effective for psoriasis, as well as psoriatic arthritis. Efalizumab is only effective for psoriasis, not for arthritis.

"Etanercept (Enbrel) and methotrexate do suppress the immune system and patients may be a little more prone to developing infections."

MEMBER QUESTION:
My 84-year-old father is taking six methotrexate pills once a week for his psoriatic arthritis. I know they also use this for cancer. I am concerned that this would suppress his immune system too much. Is this possible? And is there any other treatment or any more natural ways of keeping this under control.

LEBWOHL:
The main side effects of methotrexate are short-term damage to the bone marrow, which can be deadly, and long-term damage to the liver. Most patients requiring methotrexate have significant arthritis, and if the methotrexate is not tolerated, the next treatment usually involves biologics, such as etanercept.

MEMBER QUESTION:
Do Enbrel or methotrexate affect liver function?

LEBWOHL:
When used for psoriasis, methotrexate can cause scarring of the liver over a period of years. And for that reason dermatologists advocate periodic liver biopsies as well as regular blood tests for liver function in patients treated with methotrexate. Etanercept (Enbrel) does not damage the liver.

MEMBER QUESTION:
Is taking Enbrel and methotrexate together safe?

LEBWOHL:
Enbrel and methotrexate are commonly prescribed together.

MEMBER QUESTION:
Is Remicade used for psoriatic arthritis? If it is, how well does it work?

LEBWOHL:
Remicade is another TNF blocker that is commonly used for psoriatic arthritis, even though it is not officially approved for that. It is dramatically effective.

MEMBER QUESTION:
Does Remicade work for psoriasis as well as psoriatic arthritis?

LEBWOHL:
Remicade is one of the most effective treatments we have for psoriasis, even though it is not yet formally approved. I do want to publicly announce, and there should be disclosure on file, I have been an investigator and consultant for most of the companies working on psoriasis, including all of the manufacturers of biologics for psoriasis.

MODERATOR:
What, if any, lifestyle changes can help along with the medications?

LEBWOHL:
There are certain triggers for individual patients. For example, some patients find their psoriasis and psoriatic arthritis do better in the summer or in warm, sunny climates, so that trips during the wintertime to sunny climates helps patients. There is a treatment center at the Dead Sea, where both psoriasis and psoriatic arthritis patients benefit.

There are not any foods that have been implicated in making psoriasis better or worse. Alcohol binges have been associated with flares of psoriasis. And last but not least, cigarette smoking and stress are bad for everything.

MEMBER QUESTION:
Do you know if there are statistics on what percentage of patients with PA will at some point need to stop working?

LEBWOHL:
We have excellent treatments for psoriatic arthritis, and the goal of therapy is to allow patients to continue to work. It is essential that we treat patients early so that they don't develop deforming, disabling joint disease that prevents them from working.

MEMBER QUESTION:
Is pustular psoriatic arthritis considered as a disability for Social Security?

LEBWOHL:
Pustular psoriasis is a severe, disabling disease. It can be generalized, meaning it involves a large part of the body surface, in which case it can be quite dangerous, or it can be localized just to the palms and soles. But even when it's localized it can be quite disabling. There have been significant numbers of people who have received Social Security benefits because of pustular psoriasis.

MEMBER QUESTION:
What is the link between Crohn's disease and psoriatic arthritis?

LEBWOHL:
There is an increase in psoriasis in Crohn's disease patients. In the general population psoriasis occurs with a frequency of about 2.5%. Among Crohn's disease patients that number is higher than 11%, so it's increased nearly fivefold. Crohn's disease is associated with a kind of arthritis that has some similarities to psoriatic arthritis.

"It is essential that we treat patients early so that they don't develop deforming, disabling joint disease that prevents them from working."

MEMBER QUESTION:
I have psoriatic arthritis and it is very bad under my fingernails and my toenails. Is there anything out there to help control it? I am on methotrexate now but it has seemed to stop working, as well.

LEBWOHL:
Systemic treatments that help psoriasis often help psoriasis of the nails, as well, but there's approximately a six-month lag period to seeing the nails improve after the skin lesions improve. If methotrexate isn't enough, other drugs, such as biologics or cyclosporine, can be effective for psoriasis of the nails. But each drug has its own advantages and disadvantages.

MEMBER QUESTION:
What causes the pitting in the nails with psoriasis?

LEBWOHL:
The pitting of the nails in psoriasis is caused by psoriasis occurring in the matrix of the nail, which is the portion of the finger the nail grows out of.

MEMBER QUESTION:
I am a 66-year-old female currently on Plaquenil and Relafen. My rheumatologist says I have undifferentiated connective tissue disease, but the hand surgeon is certain I have psoriatic arthritis because of the damage to my right fingers' distal joints.

LEBWOHL:
Distal joint involvement is certainly one of the features of psoriatic arthritis, and it would be best to seek out some expert opinions to make sure you have the right diagnosis in order to proceed with optimal treatment. I suggest you contact the Psoriasis Foundation to find an expert in your area.

MEMBER QUESTION:
My husband's arthritis is especially bad in his hands and he can't even come close to making a fist. If he goes on Enbrel will that improve, or does it only help for pain and future damage?

LEBWOHL:
Primarily it helps pain and prevents future damage. It certainly does reduce swelling of the joints and may help your husband in that regard, but if there is extensive damage to joints already, it cannot reverse all of that damage.

MEMBER QUESTION:
Will Raptiva treat psoriatic arthritis?

LEBWOHL:
The earliest studies with efalizumab (Raptiva) did not show effectiveness for psoriatic arthritis.

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