Collaborative working between dermatology and rheumatology improves disease management and may reduce cardiovascular risk in psoriatic disease

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1 Collaborative working between dermatology and rheumatology improves disease management and may reduce cardiovascular risk in psoriatic disease David Burden Department of Dermatology Western Infirmary, Glasgow conflicts of interest to declare: Abbott, Janssen Cilag, Leo, Merck Serono, Pfizer, Schering Plough

2 Psoriatic disease Psoriasis vulgaris

3 Psoriatic disease Psoriasis vulgaris Palmoplantar pustulosis

4 Psoriatic disease Psoriasis vulgaris arthritis enthesitis dactylitis axial disease Palmoplantar pustulosis

5 Psoriatic disease Crohn s disease Psoriasis vulgaris arthritis enthesitis dactylitis axial disease Palmoplantar pustulosis

6 Psoriatic disease Crohn s disease Psoriasis vulgaris arthritis enthesitis dactylitis axial disease co-morbidities obesity diabetes hyperlipidaemia hypertension vascular disease lymphoma depression alcoholism Palmoplantar pustulosis

7 Why do we need to collaborate? How can it be done? What is the effect?

8 Why do we need to collaborate? diagnostic issues therapeutic issues How can it be done? What is the effect (on vascular risk)?

9 Dermatologists She has morning stiffness and pain in her knees How do you know if she psoriatic arthritis?

10 CASPAR (ClASsification criteria for Psoriatic ARthritis) criteria inflammatory articular disease (joint, spine, or entheseal) PLUS 3 points from the following 5 categories: 1.Evidence of current psoriasis, a personal or family history of psoriasis. 2.Typical psoriatic nail dystrophy 3.A negative test result for the presence of rheumatoid factor 4.Either current dactylitis or a history of dactylitis 5.Radiographic evidence of juxtaarticular new bone formation *Current psoriasis is assigned a score of 2; all other features are assigned 1 specificity 98.7% sensitivity 91.4%

11 A 56 year old woman is taking methotrexate for severe plaque psoriasis. At review, she complains of pain and stiffness in the left knee of 3 months duration with no history of prior trauma. Which of the following best describes your first response to her joint pain? 1. Try to ignore it 2. Prescribe an NSAID 3. Use a screening tool for psoriatic arthritis 4. Take a full history, measure inflammatory markers and arrange an X ray 5. Refer to a rheumatologist

12 Rheumatologists she has sero-negative polyarthritis How do you know if she psoriatic arthritis?

13 Rheumatologists she has sero-negative polyarthritis How do you know if she psoriatic arthritis? Bowens disease Lupus vulgaris DLE Psoriasis

14 How do you define severe disease? Psoriasis The rule of 10 s PASI 10 DLQI 10 BSA 10% severe disease

15 How do you define severe disease? Cutaneous psoriasis The rule of 10 s PASI 10 DLQI 10 BSA 10% severe disease Peripheral psoriatic arthritis 3 or more tender and inflamed joints

16 How do you define severe disease? Cutaneous psoriasis The rule of 10 s PASI 10 DLQI 10 BSA 10% severe disease Peripheral psoriatic arthritis 3 or more tender and inflamed joints PASI 9, DLQI 9 10 tender, 2 inflamed joints not severe disease

17 Why do we need to collaborate? diagnostic issues therapeutic issues How can it be done? What is the effect (on vascular risk)?

18 Dermatology psoriasis patient pathway updated Dec Psoriasis is a chronic relapsing condition that can usually be managed by self-care or in primary care Chronic plaque psoriasis: Localised stable plaques on extensor aspects with typical waxy scale. Guttate psoriasis: Acute onset of numerous small scaly lesions often after a throat infection. Usually self-limiting within 3 to 6 months. Scalp psoriasis: Scaly localised or diffuse plaques extending to scalp margin. May be associated with temporary thinning of scalp hair. Flexural psoriasis: Smooth, shiny welldemarcated areas in body folds. May occur without psoriasis elsewhere. Nail psoriasis: Mild disease is a cosmetic problem requiring no treatment. Conceal with nail varnish. Patient Presentation Primary Care Assess lifestyle factors which may precipitate or aggravate psoriasis: smoking, alcohol, certain medications, infections. MANAGEMENT Emollient Vitamin D analogue +/ topical steroid Coal tar Dithranol cream as short contact therapy Topical retinoid Emollient Vitamin D analogue +/-moderate potency topical steroid Coal tar Consider referral for Phototherapy Combination of keratolytic and antiinflammatory agents Calcipotriol scalp application Tar based shampoo Potent topical steroid scalp application Severe cases use keratolytic e.g. coconut, tar and salicylic ointment. Use mild to moderate potency steroids combined with antibiotic/antifungals Nail disease responds poorly to topical treatment Podiatry referral for painful toe nails Dermatology referral for severe disease Patient Primary Care Secondary Care?Refer Criteria for first referral to Dermatology Consultant: Diagnostic uncertainty Extensive disease Occupational disability or excessive time lost from work or school Involvement of sites which are difficult to treat, e.g. the face, palms and genitalia Failure of appropriate topical treatment after 2 or 3 months use Adverse reactions to topical treatment Severe or recalcitrant disease requiring systemic therapy Generalised erythrodermic or pustular psoriasis: Emergency referral is indicated Criteria for referral to Dermatology Nurse Specialist: Diagnosis established previously in Secondary Care Relapse of the disease which failed to respond to topical therapy in Primary Care Refractory scalp psoriasis Request for further counselling and/or education including demonstration of topical treatment Topical therapy/phototherapy according to protocols and nurse competencies. Primary Care Practice or Liaison Nurse or General Practitioner review to encourage compliance. Click here for printable PDF version Secondary Care Follow up Secondary Care Follow up by Dermatologist if: Very severe disease Systemic medication (shared care). Useful Information for Patients

19 So many guidelines Pharmaco-economic guidelines Professional guidelines NICE BAD biologics for psoriasis 2009 ustekinumab for psoriasis 2009 BSR biologics for PsA 2005 adalimumab for psoriasis 2008 European infliximab for psoriasis 2008 American adalimumab for PsA 2007 etanercept and efalizumab for psoriasis 2006 etanercept and infliximab for PsA 2006 SMC ustekinumab for psoriasis 2010 adalimumab for psoriasis 2008 infliximab for psoriasis 2007 etanercept for psoriasis 2006 adalimumab for PsA 2005 Etanercept for PsA2004

20

21 What do you do when there is no response to methotrexate?

22 Efficacy of Traditional Systemic Therapy for Psoriasis Response by PASI 75 at primary endpoints (8-16 wks) No head to head trials 100 Low Medium High efficacy level % Patients Achieving PASI Acitretin Fumarates Methotrexate Ciclosporin >75 Phototherapy

23 Expected discordant responses Treatment Efficacy in PsO Efficacy in PsA phototherapy acitretin methotrexate ciclosporin? fumaric acid esters steroid joint injections sulphasalazine leflunomide TNF antagonists IL12/23 p40 antagonists

24 Expected discordant responses Treatment Efficacy in PsO Efficacy in PsA phototherapy acitretin methotrexate ciclosporin? fumaric acid esters steroid joint injections sulphasalazine leflunomide TNF antagonists IL12/23 p40 antagonists

25

26

27 What do you do when there is no response to methotrexate? You prescribed a TNF antagonist

28 What do you do when the skin responds to a TNF antagonist but not the arthritis?

29 or vice versa?

30 Why do we need to collaborate? diagnostic issues therapeutic issues How can it be done? What is the effect (on vascular risk)?

31

32

33 Limited psoriasis Mild arthritis Extensive psoriasis Mild arthritis Limited psoriasis Severe arthritis Extensive psoriasis Severe arthritis

34 Limited psoriasis Mild arthritis Primary care Limited psoriasis Severe arthritis Extensive psoriasis Mild arthritis Extensive psoriasis Severe arthritis

35 Limited psoriasis Mild arthritis Primary care Limited psoriasis Severe arthritis Extensive psoriasis Mild arthritis Dermatology Secondary care Extensive psoriasis Severe arthritis

36 Limited psoriasis Mild arthritis Primary care Limited psoriasis Severe arthritis Rheumatology Secondary care Extensive psoriasis Mild arthritis Dermatology Secondary care Extensive psoriasis Severe arthritis

37 Limited psoriasis Mild arthritis Primary care Limited psoriasis Severe arthritis Rheumatology Secondary care Extensive psoriasis Mild arthritis Dermatology Secondary care Extensive psoriasis Severe arthritis?

38

39 Patterns of collaborative working Virtual or informal Speak or write to each other copy clinic letters decide who is taking the lead Agree psoriasis / arthritis protocols Combined clinics

40 Combined psoriasis / arthritis clinics who for not generally for diagnostic issues patients who fall between therapeutic guidelines discordant treatment response in skin / joints high risk patients purpose single assessment to plan strategy advantages patient satisfaction share resources and nurses education of patient (and clinicians) risk sharing efficient data management

41 Data management - the paper chase Psoriasis Pattern of disease Extent Current activity PASI DLQI Treatment responsiveness PASI75 for each treatment Cumulative dose of UVB and PUVA Psoriatic arthritis Pattern of disease Current activity tender and swollen joint counts HAQ Treatment responsiveness ACR20/PsARC for each treatment Co-morbidities Vascular risk factors Metabolic syndrome Psychological status Immune status etc

42 Combined psoriasis / arthritis clinics who for not generally for diagnostic issues patients who fall between therapeutic guidelines discordant treatment response in skin / joints high risk patients purpose single assessment to plan strategy advantages patient satisfaction share resources and nurses education of patient (and clinicians) risk sharing efficient data management disadvantages logistics unknown cost-effectiveness

43 Why do we need to collaborate? diagnostic issues therapeutic issues How can it be done? What is the effect (on vascular risk)?

44 CVD in Psoriasis: Epidemiology Adjusted relative risk of myocardial infarction in patients with psoriasis based on patient age Relative risk (85% confidence interval) Severe psoriasis Mild psoriasis Age, y Control patients n=556,995, patients with mild psoriasis n = 127,139 and severe psoriasis n = 3,837 Gelfand et al. JAMA 2006; 296:

45

46 PEST (Psoriasis Epidemiology Screening Tool) Score of 3 or more indicates PsA specificity 92% sensitivity 78% Ibrahim et al 2009

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