Psoriatic Arthritis: Moving Toward a Personalized Approach

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Dr. Caudle:
Painful symptoms like stiffness, fatigue, and even swollen fingers and toes take a huge toll on psoriatic arthritis patients, both physically and psychologically, and while there is currently no cure for psoriatic arthritis, there are various treatment options that help minimize these painful symptoms.  But how do you know which one is best for each specific patient? I’m Dr. Jennifer Caudle, and sharing her approach to treatment is Dr. Marina Magrey, a rheumatologist with the Metro Health Network in Cleveland, Ohio, and Associate Professor at Case Western Reserve University. 

Dr. Magrey, thank you for joining us. 

Dr. Magrey:
Thank you so much for inviting me to talk to you. 

Dr. Caudle:
Let’s start by talking about how you select certain drug classes over others for a patient with psoriatic arthritis.  Do side effects or a patient’s lifestyle play a role in what you recommend for them? 

Dr. Magrey:
We have multiple treatment options for psoriatic arthritis, like there’s tremendous advancement in treating psoriatic arthritis.  Earlier, we used to borrow the treatment which was in rheumatoid arthritis for psoriatic arthritis, but now we have medications available that are exclusively for treatment of psoriatic arthritis.  So, in order for us to decide how do I treat this patient, I look at the domains of the disease.  Since it is a multifaceted disease involving multiple domains, I want to make sure that we are able to treat all of them together and make the patient feel better.  We have different biologics available now.  We haven’t yet been able to develop any strong predictors of response which would really help us that we’d say, okay, you know this patient has these certain features so he’s going to be very well with this medication.  We are not quite there yet, but we’re working to develop that.  So we start with certain guidelines that have been developed by either the GRAPPA.  GRAPPA is a study group of international experts in psoriatic arthritis, so they have developed some guidelines based on these different disease domains, so we either go with the GRAPPA guidelines, or also, EULAR, which is European Union League Against Rheumatism, has also invested guidelines, so we kind of use those as a framework on deciding how to treat these patients. 

Dr. Caudle:
As you’re looking at the guidelines and you’re considering different factors, let’s talk about the therapies.  Are all therapies created equally when it comes to treating both the skin and the joints in psoriatic arthritis? 

Dr. Magrey:
To talk about the treatment is we usually try to start with what we call a disease-modifying antirheumatic treatment, DMARDs.  So we start with DMARDs—because DMARDs they didn’t traditionally use for treating rheumatic diseases—and safety with these is good.  It’s proven that they’re not dangerous drugs, so often we start with that.  And then if a patient doesn’t respond to a traditional DMARD, then we move to a different class of medications, and usually we’ll switch to biologics. Now, there are certain conditions, like if a patient has dactylitis or enthesitis, traditional DMARDs, may not be as helpful, so we may start with just a simple nonsteroidal anti-inflammatory medication and then move straight away to a biologic to give them relief if they are showing inadequate response to nonsteroidal anti- inflammatories.  Now, in biologics, we have many classes of biologics now available for treatment of psoriatic arthritis.  We have tumor necrosis factor inhibitors, TNF inhibitors, multiple of them, and all of them have been efficacious in treating psoriatic arthritis.  And now we have developed specific biologics that target IL-17 cytokines.  We have biologics that will target IL-23, IL-12 cytokine.  And there is now newer ones which are working—which are also affecting a different pathway called… One works on the Janus kinase pathway, and another one works on phosphodiesterase. 

Dr. Caudle:
And do you recommend alternative therapy options to your patients?  And if so, which ones are they? 

Dr. Magrey:
There is not much, because unfortunately, alternative therapies, since they are not FDA approved and there is no head-to-head studies done with these medications, over-the-counter or alternative medications, we don’t recommend them to the patients for treatment because we don’t know if they’re going to work or if they’re not going to work, and they do have side effects.  Often patients think that these medications don’t have side effects, but they have not been systematically tested, so that’s why they feel like there may be no side effects because they’re not reported.  So I will tell patients that psoriatic arthritis is an immunologically mediated disease, and the therapies that are approved is what I would like you to take. 

Dr. Caudle:
Lastly, what new and exciting advancements are in the pipeline for psoriatic arthritis?  What do we have to look forward to? 

Dr. Magrey:
So there’s going to be a lot more biologics coming out.  There’s very targeted therapies which are going to work on specific cytokines that are being developed, and some of them are going to work for multiple cytokines, so we’re all looking forward to these newer therapies, these targeted therapies, so that we feel that they may be able to control all facets of the disease much better. 

Dr. Caudle:
Well, these have been great insights into what’s currently available and even what we have to look forward to when it comes to treating psoriatic arthritis, and I want to thank my guest for providing us with this valuable information.  Dr. Magrey, it was a pleasure speaking with you. 

Dr. Magrey:
Thank you so much, and it has been a pleasure talking to you too.