This transcript has been edited for clarity.
Stanley Cohen, MD: I'm Dr Stanley Cohen, and I want to welcome you to Medscape's InDiscussion series on psoriatic arthritis. This is episode 2 of the second season. Today, we'll be discussing shared decision-making strategies in psoriatic arthritis management. First, I want to introduce my guest. I'm very happy to have one of my old friends and colleagues, Dr Eric Ruderman. Dr Ruderman is the associate chief clinical affairs for the Division of Rheumatology at Northwestern University and a professor of medicine at the Feinberg School of Medicine. Welcome to InDiscussion, Eric.
Eric M. Ruderman, MD: Thank you very much, Stan. Pleasure to be here.
Cohen: Well, glad to have you. Just a quick question, which I like to ask all the folks that we have on this podcast. I'm always interested to understand how someone came into rheumatology. What was your impetus for looking into rheumatology training and then becoming an academic and clinical rheumatologist?
Ruderman: Not everybody knows that my father was a rheumatologist, so I sort of grew up with it and I knew that he loved what he did. When I started to get on the path to internal medicine, it was very clear to me that that was the most interesting field. I really enjoyed the chronic management piece of this, knowing people for a long time and really getting to know them and helping them with their disease, especially now that we can do some really positive things in terms of disease management.
Cohen: That's one of the beauties of our specialty — we really get to know our patients. I'm a little older than you are. I've had patients for 40 years, and certainly the advent of targeted therapies and directed therapies has really made being a rheumatologist a lot more fun. Part of our role in the clinic, and when we're working with patients and talking about potential new therapies, is this concept of shared decision-making; this is applicable to psoriatic arthritis but also to any of our particular diseases we manage. If you could or would, please define what you feel shared decision-making is.
Ruderman: It's come across as sort of a new concept, but to me in many ways it's just good medical care. It's the idea of making treatment decisions with your patient and working together to come up with the best plan of action. There are very few places in medicine where there's a single best treatment — perhaps an infection that's going to respond to a particular antibiotic or something like that. In most cases, there isn't one option only, there are multiple options, and then there are a lot of things that go into those choices depending on the outcome you're looking for, the possible side effects of the different treatments you're thinking about, the difficulty of getting those treatments, et cetera. To me, shared decision-making is really the way to bring the patient into that decision, as they should be, so that you can make plans that engage them all the way through.
The other plus to this, which almost goes without saying, is that when the patients are involved, when your patient is involved with a treatment decision, they're going to be more apt to stick with that treatment decision. I've never thought it's good medicine to say, this is what you're going to do and prescribe a medicine and tell them to go off and do it. Because people are not always likely to do that if they don't feel they're engaged in the choice to treat it that way.
Cohen: I agree. And medicine has become so complicated that I think it's critical that we do spend time with our patients and go through the benefits and risks. Also, I'm sure you would agree as well, patients are much more educated about disease processes and therapies these days, and they're also misinformed in some ways from the Web so that they need to rely on providers, clinicians, to give them the proper information to participate in the process. But I think you're 100% correct: Having buy-in from the patient from the onset is critical.
I know that you have put together some examples of cases where shared decision-making was critical. If you would proceed, let's go through them and talk about some of the issues with each of the cases.
Ruderman: I picked some patients I've seen very recently. I have for many years done a clinic with one of our dermatologists at Northwestern in psoriatic arthritis. What happens there in many cases is that it's three-way shared decision making between myself and the patient and the dermatologist, because when you're dealing with psoriatic arthritis, you're really dealing with psoriatic disease that can have a bunch of different manifestations at any given time, and in any given patient, one or the other may be more important, either globally to their health or specifically that particular patient. So I picked a few cases that we came across in the past few weeks to illustrate that.
The first was a young woman I had seen a couple weeks ago. She was 36 years old and had a history of fairly mild psoriasis that had been managed mostly with topicals and some intermittent phototherapy for many years. She had an episode of strep pharyngitis and developed a really bad flare of guttate psoriasis shortly after treating the strep pharyngitis, which is not unheard of. It's certainly been seen. And with that skin flare, which was what really brought her into our clinic, she also had more pain in her right wrist. She's a nurse, and it really made it tough for her to do her job.
We evaluated her and had a very in-depth conversation between myself, the dermatologist I work with, and the patient on what the different options were. In this case, it was her skin disease that was driving the decision-making — this profound explosion of guttate psoriasis. We made a decision to use an interleukin-17 (IL-17) inhibitor because it was going to be much more effective at helping her skin than perhaps the tumor necrosis factor (TNF) inhibitor. Her wrist was problematic. It wasn't terribly inflamed when I saw her, though it was hurting enough that it made it difficult at work. I felt that an IL-17 inhibitor should be reasonably adequate to manage that wrist pain and if it controlled the skin, she'd be in a better place. We talked a bit at the time about using an interleukin-23 (IL-23) inhibitor because of perhaps even better skin response. I was a little concerned about the wrist, and I wanted to make certain that we got her joints under control. I know that the IL-23 inhibitors have been approved for psoriatic arthritis, but I think we still don't have a strong sense of where they fit relative to TNF and IL-17 inhibitors in terms of how effective they are at controlling joint disease.
In any case, we ended up putting her on an IL-17 inhibitor, ixekizumab per her insurance, and we saw her about 6 weeks later. Her skin was remarkably better, nearly clear, and the wrist was better too. Not completely — it still is a little achy, but it really didn't interfere with her day, and she was back to work. So we kept her on that and she's doing well. And I think that through that combined discussion with the three of us, we came up with a plan, and fortunately the plan worked out quite well.
Cohen: This is a typical example of the type of patient that we see in the clinic. I think it's interesting that that you made the decision to go with IL-17 over the TNF inhibitor, and you might talk a little bit about the domains of psoriatic arthritis and the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and other professional society recommendations. I know that GRAPPA, which is a group of rheumatologist and dermatologist investigators, is finally going to have their new recommendations come out later this year. Take us through the risk stratification, which you look at when you're trying to determine what type of therapy, when you take a look at the different domains of the disease.
Ruderman: The GRAPPA guidelines, now in the third iteration, have been really helpful all the way through because they took a very unique approach to managing psoriatic disease. GRAPPA is an organization composed of rheumatologists and dermatologists, and they looked at the different domains of disease activity. So there's certainly joint disease and synovitis, but in terms of musculoskeletal disease, there's also axial disease. In some people, there's enthesitis, which is a big piece of what happens in psoriatic arthritis, and there's the dactylitis, and all can be somewhat separate in terms of how bad they are and what might treat them.
Then there's the skin disease and in many patients, particularly the patients who have both skin and joint disease, there's nail involvement. The way that GRAPPA looked at their recommendations was to look at the efficacy of all the different treatments that we have for each of those individual domains of disease. You know what's going to work well for skin disease; what's going to work well for dactylitis? What might work well for joint disease or for nail disease? And then rather than being dogmatic about a natural hierarchy of therapies, they said, these are the therapies. You have to evaluate the patient on an individual level and say, which elements of disease are you most interested in treating? And then pick your therapy to get at all of those. They lay out a grid that says, here are the treatments for the different individual components. Look at what's going on in your patient at this time and come up with a plan that minimizes having to use multiple drugs but still addresses all of their issues.
One of the things that we found, and it goes back to the shared decision-making issue, is that different manifestations of disease are more important to different patients. I have patients whose skin disease is a big issue for them, and yet I have other patients whose joint disease is their real problem and they're not terribly concerned about their skin disease. They kind of blow it off and say, it's no big deal. In many cases, they have more skin disease than I would be comfortable with, but they're okay with it. Part of our discussion is to try to figure out what we are going to focus on making better. Ideally, you want to make everything better, but you can't always do that. So how do you focus your treatment?
The other piece of that that often comes up, and I have this discussion with patients all the time, is that skin disease is all epidermal. It's not going to scar. If somebody has bad skin and you don't treat it aggressively, but then you decide to do so later, you haven't really lost anything because you can always clear it at some point down the road if it becomes more problematic or they're more bothered by it. Joints are a bit of a different story, particularly the patients who have erosive or destructive disease. If you get behind, you can never catch up. And that's a discussion I often have with patients as we embark on shared decision-making and say, look, you know, your skin, you may be able to make those calls when I think you're making a bad choice for your joints, because I'm worried about future damage and not being able to recover from that. I'm going to tell you that. And we'll look at other options.
Cohen: That's a very good summary. I agree with it. We certainly have used the GRAPPA guidelines to allow us to stratify our patients and pick the domains which are of greatest concern to us and the patient and initiate therapy. Let's go on to case two and see what your approach was for this particular patient.
Ruderman: This was another patient we saw recently in the same combined clinic, and this was more of a question of toxicity than efficacy. This is a 66-year-old man with a history of cirrhosis from hepatitis C who was on the transplant list and awaiting transplant. He came to see us because he had a history of psoriasis, which had developed about 8 years ago or so. He was treated initially with topicals. For the past couple of years he'd been on apremilast, which helped some, but gradually started to have more progressive psoriasis despite apremilast, and he was also having some gastrointestinal (GI) side effects that weren't entirely limiting, but he wasn't thrilled by them. He's also had some joint pain that's been ongoing. It had responded to the apremilast, but as he lost response, some of that has been more problematic, particularly his hips and his shoulders.
When he came in to see us, he reported some low back pain, not too bad. It wasn't bothering him very much. It was causing some stiffness in the morning, but it really didn't limit him. He had pretty active psoriasis on his extremities and on his back, ears, and genitals, and he needed to do something. It was very clear for him that the back wasn't really limiting, but the skin disease was. We discussed everything with him and with the dermatologist.
In this case, we made a decision to recommend an IL-23 inhibitor, the idea being here that the toxicity and particularly the risk for infection clearly appear to be lower with that pathway. This is a guy who had end-stage liver disease, was headed into transplant at some point in the not-too-distant future, was going to be on immunosuppressants, and was clearly at higher risk for transplant-related complications and infections. We felt that the safety profile of an IL-23 inhibitor really made the most sense for him. We cleared that with hepatology, and we're waiting for his insurance to approve it and move ahead. I can't tell you how he's doing, but that's the plan.
I will tell you interestingly about this guy, at the time of the visit, we sent him for some x-rays particularly to look at his sacroiliac joints. He did have some sacroiliitis, which went with the back pain and the stiffness he described. But again, it wasn't terribly problematic for him. I have some concerns about how effective the IL-23 inhibitors are for axial disease and psoriatic arthritis. I think that there's some evidence of benefit, but I'm not convinced they're as good as some of the other pathways. And yet in this case, his back wasn't a big problem. And the toxicity, to me and to him, outweighed that. When we talked about it, we decided to keep going with the IL-23 inhibitor, despite the evidence of sacroiliitis that he had.
Cohen: And at age 66, he may have burnout sacroiliitis.
Ruderman: Really, I have no idea. I think he still has some symptoms. And it was clearly there. I would say that if his low back symptoms were a really big problem for him — if he said, this is a really big issue for me and it's limiting what I can do during the day — then I probably would have recommended a different choice. We might have leaned toward a different pathway that I felt more comfortable was really going to clear up his back pain.
Cohen: This is a very complicated patient to manage, and obviously you had to reach out to the hepatologist to make sure that they're on board with whatever you were going to choose, with future transplant and immunomodulation. Just curious, what's your take? Clearly the IL-23 inhibitors, based on the clinical trials, have wonderful safety data. I don't want to put you on the spot lacking head-to-head trials, but I'm going to put you a little bit on the spot. Do you think they're safer than IL-17 inhibitors? I think they are safer, at least on my take on non–head-to-head trials from TNF inhibitors. But I'm just curious what your thoughts are as far as IL-17.
Ruderman: I don't know, I suspect maybe a little bit. You're right, we don't have head-to-head data. It's going to be a long time before we know for sure. But my sense, looking at the clinical trial results so far with IL-23 inhibitors, both in joint and skin disease, is that the risk, particularly for infection, is a lot less. [The IL-23 inhibitors] don't seem to have the risk for candidiasis, which is a sort of a unique issue to the IL-17 inhibitors. That's not a dealbreaker for most patients, but it is something we certainly see occasionally and do have to discuss with them. Honestly, absent good data, my sense is that the IL-23 inhibitors are going to be less risky for treating infections. But I just can't prove that. I will say that that's clearly the perception in the dermatology community. And when you talk to the dermatologists, one of the reasons they've jumped headfirst into using IL-23 inhibitors, pretty much as their first biologic of choice when they can, is the safety and to a certain extent the infrequent dosing, which is really nice.
Cohen: I've always felt that rheumatology is very risk-averse. Dermatology makes us look like we're aggressive. But so very clearly, you know, for patients who have a large bulk of skin disease and less joint disease, then IL-23 or IL-17 inhibition is probably the way to go at this point. The TNF inhibitors are great both for joints and skin, just not as great for skin as IL-17 and IL-23 inhibitors. So let's go into the third case as we wrap up.
Ruderman: This is another gentleman, an older gentleman, who has had a history of mild plaque psoriasis for about 15 years and about a year and a half ago developed some polyarticular arthritis for the first time — hands, feet, and knees, and some dactylitis in his second toe on one of his feet. He has a history of hypertension and hyperlipidemia, both of which are managed well with medication. He does have a family history of coronary artery disease, with a brother who had a myocardial infarction (MI) at a relatively young age. He's got some nail changes concurrent with the development of his psoriasis. More recently, he's been treated with some nonsteroidal anti-inflammatory drugs (NSAIDs) and, eventually, methotrexate up to 25 mg/wk without really fully controlling his synovitis or the dactylitis in his toe. The psoriasis hadn't been as big a deal, but his joint pain was ongoing. His erythrocyte sedimentation rate and C-reactive protein (CRP) level remained elevated. We talked to him and because of this active disease, we decided it was time to escalate therapy from just the methotrexate. He wasn't really thrilled about injecting himself with a biologic and asked about a pill like upadacitinib that he'd seen on TV and ads for psoriatic arthritis.
I think this case illustrates some of the safety things we think about, because we had a discussion with him. As you are well aware, Stan, the FDA has issued some recent guidance on Janus kinase (JAK) inhibitors based on the oral surveillance trial with tofacitinib that suggested a higher risk for both cardiovascular events and malignancy in high-risk patients, for older patients with underlying risk for cardiovascular disease, which is basically this guy. Having had that discussion with him, we thought that it probably would be prudent to start with a TNF inhibitor, even though he wasn't thrilled about injecting himself. We said to start with that before going straight to a JAK inhibitor.
There is the other wrinkle of the way that the way the labeling is written, you're supposed to fail a TNF inhibitor before you can get a JAK inhibitor these days, even though we don't have that data in psoriatic arthritis to show that. Just in terms of general safety, we felt it was a better move for this guy.
Cohen: Our role in this is incredibly important to educate the patient and make sure they understand the benefit-risk equation. For this particular patient, I would agree that the JAK inhibitor was not the best choice. I saw a patient earlier this morning who has a history of endometrial cancer, has a stent for coronary artery disease, but in whom everything had failed. She had not taken the newest JAK inhibitor, upadacitinib, and that's what she wanted to take. We spent a great deal of time in discussion with her; went through the data; and had her agree to sign a document, an informed consent that she understands that she's at risk. As long as we've had discussions. They're relatively contraindicated for those patients, not absolutely contraindicated for those in whom other therapies have failed. But again, this has been very interesting. And I think shared decision-making is an incredibly important part of our daily activities and, we're all attuned to it. And medicine has changed. In my 43 years, the doctors were the el jefes; they made all the decisions, and you do what I tell you to do or move on. Those days are long gone.
I very much appreciate your insight into this and these really fascinating case reports that you've put together. Thanks for being with us, Eric. Much appreciated.
Ruderman: My pleasure. It was really enjoyable.
Cohen: Thank you for joining us for episode 2, and I look forward to another great discussion in episode 3. This is Dr Stanley Cohen, for InDiscussion.
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Cite this: How to Optimize Shared Decision-Making in Psoriatic Arthritis - Medscape - Jul 20, 2022.