Recently, I completed a trial in the office I have worked in for 21 years. It struck me how infrequently I assessed psoriasis (PsO) patients for psoriatic arthritis (PsA). Since we have had an electronic medical records (EMR) system since the mid-1990’s, I was able to head back in time and found that any of our nearly four dozen providers across the dozen offices only assessed for PsA less than 5% of the time. You would think that PsA, a rather inflammatory condition that can cause pain, fatigue, swelling and joint stiffness that can include impaired physical function, a high psychosocial burden, reduced quality of life and work disability would be high on our list as providers, but it hasn’t been. Just casually asking around with colleagues, the common answers included the lack of time, or that the patient didn’t mention pain, or worry what to do with a finding that may require a referral to rheumatology – something we don’t have much in our area. But with some studies finding that 30% of patients with psoriasis (PsO) will develop psoriatic arthritis and associated with serious comorbidities such as depression, diabetes, dyslipidemia, hypertension, obesity, osteoporosis, uveitis, various levels of bowel inflammation, and cardiovascular disease, what was I missing?
Apparently, a lot.
I began doing two things: first, I chose the use of the PEST – Psoriasis Epidemiological Screening Tool. It is non-proprietary (free to use) and has high validity, sensitivity and reliability. If the patient responds “Yes” to three of the five questions, most likely they are positive for PsA. It is easy to find on the internet. Second, I asked for the patient pain level using the familiar Wong-Baker FACES smiling to sad line drawings I saw in hospitals as a young nurse – the old “scale based on one to ten”. That way, I would have a baseline number to improve.
Until recently, there were not many very effective treatments for PsA but with the relatively new advent of biologics approved for both PsO and PsA, with their specific targeting, low side-effect panels and absence of ‘black-box’ warnings, healthcare has excellent tools to better control of the disease and its consequent comorbidities and decreasing pain. In study after study, early diagnosis is crucial in preventing damage in patients with PsA.
In fact, it has been determined that a delayed PsA diagnosis is strongly associated with worsened physical function, and even a 6-month delay from symptom onset to the first visit with a health-care provider results in worse outcomes for individuals with PSA.
So, what was the final upshot?
Nearly half of my PsO patients that were not receiving any biologic treatment were positive for PsA! That is way off the current research articles and shows how serious the problem is. Pain scales have been improved significantly for many patients, even as little as one month. And many patients did not realize that they could live better lives with more targeted therapy.
Happy patients have made for a better day because of improved outcomes. I hope this insight does the same for you.
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