How and When to Escalate PsA Treatment
Announcer:
You’re listening to ReachMD. This episode of Living Rheum, titled “How and When to Escalate PsA Treatment” is sponsored by Novartis US Clinical Development and Medical Affairs. The host and speaker have been compensated for their time. This program is intended for health care professionals. Here’s your host, Dr Ethan Craig.
Dr Craig:
As we've discussed in our other episodes, in this podcast series, the treatment of psoriatic arthritis, or PsA for short, revolves not only around arthritis, but also around various domains of disease activity that unfortunately often refuse to behave together. That's why treating PsA is often a joint endeavor with patients, and we have to determine when domains to prioritize. So how and when should we escalate or change treatments in patients with psoriatic arthritis? That's what's to come in this podcast.
Welcome to ReachMD, and I'm Dr Ethan Craig. Joining me to discuss treatment escalation is Dr Alexis Ogdie. Dr Ogdie is an Associate Professor of Medicine and Epidemiology in the Perelman School of Medicine, and she's the Director of the Penn Psoriatic Arthritis and Spondyloarthritis Program at the University of Pennsylvania. Dr Ogdie, thanks for being here today.
Dr Ogdie:
Thanks so much for having me.
Dr Craig:
So, in thinking about the question of escalation of treatment in psoriatic arthritis, it's probably best to review some of the groundwork. So, with that being said, Dr Ogdie, what are you working with, generally, as your target to treat in PsA? And to what extent is your decision-making driven by a shared process with the patient?
Dr Ogdie:
Well, first, I’ll start with the target that I use. So, when I'm in clinic, I'm monitoring several different things. One is the tender and swollen joint accounts, the patient pain, the patient global assessment, the patient's function, their skin disease, and then their enthesitis. So, we want to make sure that all of those components are doing well in general. Meeting minimal disease activity is meeting 5 of the 7 criteria.
So also, though, you mentioned the role of shared decision-making, that's probably the most important part. So, I want to use my assessment to inform how active I think the disease is, but then really get their opinion on how they're functioning and how they're doing and what's bothering them the most and how important it is to feel better in a certain domain. So, for example, the other day I saw a patient who was doing, you know, fairly well, but she really wanted to improve her, from my perspective, so her skin was fully under control. Her joints were substantially improved, a couple swollen joints. Yeah, so she didn't quite meet all the MDA criteria. But what she really wanted, was to be able to get back to playing basketball again. And so instead of switching therapies for her, even though she had - she didn't quite meet MDA, one of the things that we talked about was physical therapy and kind of getting her up and functional again. So just because you're not meeting MDA, it doesn't always mean that the next thing you need to do is switch therapies because she came from 12 joints down to 2. So, you know, it's important to think about what the patient wants and what the patient needs, as opposed to only switching based on MDA.
Dr Craig:
So, we often end up reaching for biologics in treating patients with PsA, but if we start at the bottom of the ladder, who are the patients that you see as candidates for treatment with oral conventional or targeted synthetic disease-modifying drugs in PsA?
Dr Ogdie:
Great question. So, if a patient has oligoarticular disease, or is, you know, not that bothered by the disease or, you know, can tolerate a slow ramp-up or doesn't really is not quite ready for a biologic or injectable medicine, then we will start with the oral therapies. Additionally, there may be some people where I just want to kind of get a sense of what's going on a little bit more, so we might want to try and I think maybe they're going to need combination therapy, I might start with the oral therapy first, for example, and then give it some time to work. So, I would say though, the majority of people are going to be those patients with more mild disease, or those that don't want a biologic yet.
Dr Craig:
And taking that as a baseline, what disease feature will lead you to jump right into a biologic rather than going to an oral small molecule drug?
Dr Ogdie:
Well, the primary one is going to be axial disease. So axial disease does not respond to those, so a lot of times we see people starting patients with axial PsA on sulfasalazine. But you can't really expect so much from sulfasalazine for the axial disease. In fact, in the axial disease recommendations, they no longer suggest using that. So, we go straight to a biologic if they have, SI joint films that have, imaging evidence of sacroiliitis, or an MRI, for example, with sacroiliitis on imaging, any of those things that suggest active axial disease, go to a biologic first.
But some other things that we might think about are patients with more severe skin disease. Those are the patients we have good biologics for severe skin disease, so we go straight to those in general.
And then finally, other considerations would be things like uveitis. So, uveitis that's recurrent might require, a biologic first. Enthesitis has been really bad or dactylitis, or poor prognostic factors like polyarticular disease or erosive disease at baseline, those things might suggest being a little more aggressive with therapy right away. And so, in that patient population, we’ll start a biologic first.
Dr Craig:
So, with all that being said, let's take the scenario of a patient that you see in clinic who's currently on a biologic drug. So, let's say they've had an overall fair response. Their psoriasis body surface area is down to about 1%, from about 5%, they may have 3 swollen joints, down from 10, and 2 tender joints down from 6. They've had a partial response, which is fairly common. When you encounter this situation, how do you decide on escalation? And how do you balance kind of adding an oral small molecule versus switching biologics or other approaches in these patients?
Dr Ogdie:
That's a great question. So, I mean, this is where shared decision-making is so important, because we don't really have the evidence yet to know what to do with that patient, and like, as you said, it’s very, very common. We see partial response all the time. So, they still have 3 swollen joints and 2 tender joints and, you know, some skin. It's not so bad, but that might be an opportunity to add an oral small molecule to see what additional benefit you can get. Now, let's say that interim visit is it like, you know, 8 weeks or 2 months 3 months or so, then you may say, ‘Well, let's wait a little bit longer to see how you're doing and just supplement some NSAIDs and topicals,’ for example. But if this is already out at 6 months, that's where the oral small molecule may come in, and that can be done at any point along the way. But also, if it's 6 months out, and we're not getting to a point where the patient is feeling much better, even though their joint counts have improved, we may consider switching therapy too.
I tend to try to like to add or maybe even increase the dosing of the biologic that is not, always easy to do, depending on what medication you're using. But if you can increase the dose, that's a good opportunity too.
I tend to be more averse to switching biologics, particularly within the first 6 months to make sure that we give the biologic at least all the time that we can to get working, because we know that some people don't fully respond until up to 6 months. So, they could continue to have clinical benefit, after 3 months. But at 6 months, if the patient's telling, you know, ‘Right before my next dose, I'm feeling much worse, I'm having a prolonged morning stiffness of a couple hours,’ you know, that's the patient that’s probably going to switch and say, ‘This is might not be working for you.’ So that's a really, circular answer, because it's really hard. It really does depend on each individual patient.
The one other thing to add there is that, are there other things you can do to make them more comfortable? For example, if they – could they – have they done physical therapy yet? And could they get that going to see if that can help a little bit as well in the interim? But in general, with 3 swollen joints still, there's something more to do still.
Dr Craig:
Now, you know, there's a huge amount of ground to cover on this topic, more so than we can probably cover in this short time. But before we close, Dr Ogdie, is there anything else you want to add here? Or any other points that you might want to emphasize as take-homes?
Dr Ogdie:
One of the key things that I like to talk about is that when we think about treat-to-target, and the way we've been trained in treat-to-target is really focusing on joints and, you know, joint swelling, and maybe in psoriasis – or in psoriatic disease, though psoriasis as well. But often, that leaves a whole range of things the patient is experiencing, that we are not addressing. And so, this is where the role of adjunct therapies can be really important. We're getting a trial off the ground to address this too. Are there easier ways to address this?
But some things to think about are number 1, is the patient obese? Can they, can you help them lose weight in some way, whether that's, you know, signing up for a weight, reduction app, or weight program, or sending them to a nutritionist or to the primary care doctor, just to talk about weight loss strategies. Even bariatric surgery when we get to that point.
Number 2, is there depression or anxiety? Because that can really drive symptoms. And I think that the stress of those 2 conditions can also, in my view, increase the - the inflammation that we see as well. And we know that those patients don't respond as well to therapy. So, can we address that? So, sending them to therapy or even to psychiatrists or, again, just to primary care to address the depression and anxiety.
Other things to think about are there adjunct therapies that can help with the pain? Because some patients have a lot of pain leftover whether or not there’s swelling or not. So, using the some of those older medications like amitriptyline, gabapentin, pregabalin, those kinds of medicines can help with pain. But pain management might be able to help there too.
In addition, other adjunct therapies like acupuncture. Acupuncture can provide a lot of benefit. Next addressing, you know, if people have really high stress that again, can cause that, you know, continued pain cycle and disrupted sleep, which also leads to poor outcomes as well. So is there a way you can help them deal with the stress, either through meditation, or getting involved in yoga or something that's going to help them reduce stress. And a lot of times, that's therapy as well. So again, using the mental health resources available to us to help with those aspects, or even sleep medicine if it's a purely sleep issue.
And then fatigue is very common in our patients, and one of the things that we know helps with fatigue is regular exercise. So regular physical activity, it has lots of benefits and for cardiovascular health, but also probably for our arthritis patients as well. So, getting them moving is really important.
And then finally, back to physical therapy. I already mentioned this, but I think physical therapy is important for every patient. Once the swelling is gone, people can still have, pain leftover in that joint, and physical therapy can help rebalance those muscles again, and make things feel better. So, in addition, a lot of our patients have noninflammatory pain as well, and the physical therapy can be really beneficial for that.
So, lots of things to think about. Don't think about just switching the therapy, but think about what else can you add to make this patient's quality of life improve?
Dr Craig:
Well, with those key takeaways in mind, I want to thank my guest, Dr Ogdie, for helping us better understand escalating PsA treatment. Dr Ogdie, as always, it was great speaking with you today. Thank you.
Dr Ogdie:
Thanks so much for having me.
Announcer Close:
This industry podcast was sponsored by Novartis US Clinical Development and Medical Affairs. If you missed any part of this discussion or to find others in this series, visit reachmd.com/living-rheum. This is ReachMD. Be part of the knowledge.
When should we escalate PsA treatment? Understand the signs and symptoms to look out for.
So how and when should we escalate or change treatments in patients with psoriatic arthritis (PsA)? To answer this question, Dr. Ethan Craig is joined by Dr. Alexis Ogdie-Beatty from the Perelman School of Medicine at the University of Pennsylvania.
Dr. Craig and Dr. Ogdie-Beatty are Novartis consultants.
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