Expert Perspective on the Management of Psoriatic Arthritis - Episode 4

Psoriatic Arthritis: Establishing Goals of Therapy

Goals of therapy and considerations that need to be factored into treatment decisions for patients with psoriatic arthritis.

Lana Dykes: What are the goals of therapy and factors that guide treatment selection for patients with psoriatic arthritis?

Christopher Parker, DO: Let me talk about goals of therapy first. I like to spell out the goals of therapy when I first meet a patient. I’m a military-minded guy, and I think about exit strategy. This is super important.

How do you know if you’ve won? Well, with psoriatic arthritis, as I mentioned earlier, to me there are 2 parts of that equation. One is the skin. “I want you, the patient, to help me understand where you’re at with that.” Because if you tell me it’s minimal, it’s minimal to me.

In regard to the joints, how do you know if you’ve won? What are my goals? I say, “Listen, I want the inflammatory activity completely controlled.” What does that mean? Well, it means on the sick joints that you have, if there are some that I can see and feel, I shouldn’t be able to detect any inflammatory activity, meaning they shouldn’t be swollen or tender, or minimally so. I gauge the amount of morning stiffness somebody has. I’m generally shooting for under 30 minutes. And I shouldn’t be able to identify any inflammatory activity on what I call other tests, such as laboratory tests. If your inflammation markers in the blood continue to be high, I’m still not happy. I feel like there’s low-grade smoldering activity that, over time, could result in damage. It’s very important to try to control that.

The same thing applies with imaging. Some people are really adept at using ultrasound. If they’re still detecting inflammatory activity with that tool, it would bother me even if the patient says, “Oh, I’m pretty good now.” And the same thing applies with advanced imaging like MRI. If I have to periodically assess somebody with that excellent technology, if you will, because they also have some degenerative issues or trauma that makes it really hard for me to figure out if they still have inflammatory activity, if I see inflammatory activity, meaning white matter lesions on T2-weighted imaging and stuff like that, I want to augment therapy. So I use all of those things to help me understand whether the inflammatory activity is controlled—history, physical, data.

Lana Dykes: Back to the second part of that question, what are the factors that guide treatment selection in patients with psoriatic arthritis?

Christopher Parker, DO: That’s complex, and is certainly on the minds of all patients. Many things guide treatment selection. No. 1, very importantly, is other comorbid problems a patient has. It would be nice if they only showed up with 1 problem. That would make my job easy. But that’s not the case. So the other things they bring to the table are going to be important in decision-making. I try to understand their behaviors and rituals right away. If they are the type of person who is really hit and miss on taking medicines, getting labs done, doing follow-ups, that’s going to be another problem. I start thinking about ways I could get that patient tied to the therapy. I might be thinking about parenteral therapy or an IV [intravenous] therapy or something like that. But that’s not a common situation. I’m just bringing up a variable.

Safety is always super important. Patients worry about that and so do we, in medicine. If they have any medical problems that make me think, “Oh, this is going to be a real safety problem here,” I want to think about that as well.

Another thing I want to go on record saying for my peers to contemplate is we need to consider our personal experience in doing medicine. It bothers me when I hear a patient tell me, “Another doctor that I saw said I could really use any of these 3 medicines.” They were given pamphlets for all 3 drugs. “You decide.” How can they decide? They’re never going to know what we know. And, it’s unfair for them to do that, or to even try. I feel like we need to really help guide them into the pros and cons of each medicine so that we, together, can make the right choice. But never should I hand it to them to figure out. I have 20 years of experience, more than that, that I should bring to the table in the decision-making process. I never want patients to feel like they have to make these kinds of decisions. That’s what they pay me for. That’s what they know me for. That’s why they travel far to see me. They want me to help them. So my personal experience with the medicine is important. They often ask, “If it was you or your mom or whomever, what would you want?” I want that to come to the table for discussion.

Transcript edited for clarity.