Alice Gottlieb, MD, PhD: Preventing Pain and Disability in Psoriatic Disease

At the 2024 Society for Investigative Dermatology Annual Meeting last month in Dallas, Texas, Alice Gottlieb, MD, PhD, spoke to attendees about the importance of multidisciplinary care in psoriatic disease, monitoring patients with psoriasis for symptoms of arthritis, and easing pain and preventing disability.

Gottlieb is a clinical professor and medical director at the Icahn School of Medicine at Mount Sinai in New York, New York, and has conducted extensive research in the fields of dermatology and rheumatology.

"I was first to show, actually, that monotherapy with a TNF blocker cleared psoriasis, which I believe opened up the field to biologics for psoriasis," she said. "I would argue that if there weren't successful biologics for psoriasis, we wouldn't be talking about biologics for atopic dermatitis or alopecia areata."

Transcript

Alice Gottlieb, MD, PhD: I'm Alice Gottlieb. I'm a dermatologist and rheumatologist. I run the program at Mount Sinai Union Square. I was first to show, actually, that monotherapy with a TNF blocker cleared psoriasis, which I believe opened up the field to biologics for psoriasis. I would argue that if there weren't successful biologics for psoriasis, we wouldn't be talking about biologics for atopic dermatitis or alopecia areata.

The subject of my talk with the critical role of the dermatologist in preventing disability and pain due to psoriatic arthritis. Why do I feel it's so important? Because psoriatic arthritis is common in about 25 to 30% of psoriasis patients. In most cases, it's not difficult to diagnose, and if we make a mistake and send a fibromyalgia or rheumatoid arthritis patient to the rheumatologist, they still need to be seen by a rheumatologist. However, if we miss the diagnosis of psoriatic arthritis, we may be causing increased disability and pain. A delay in 6 months or more of diagnosis means a worse prognosis in terms of X ray findings, mutilating arthritis, a poorer quality of life. It's important to diagnose early, because psoriatic arthritis is potentially disabling. It is a real shame that in up to 41% of cases, the diagnosis of psoriatic arthritis is frequently missed by dermatologists, and we have a long enough time to think about it, because the cutaneous disease precedes the arthritis in most cases, in adults, by 10 to 12 years. We're the first who can detect psoriatic arthritis.

Why does it matter? Because we have multiple TNF blockers, interleukin 17 blockers, a JAK inhibitor, which not only controls signs and symptoms, but inhibits radiographic progression, so we can prevent disability by initiating treatment early on. Frankly, I don't know how you can tell how to treat a psoriasis patient if you don't know whether they have psoriatic arthritis. Many psoriatic arthritis patients present with very little skin disease. If the dermatologist doesn't ask, they're going to give them a topical medication and miss the point that they have joint disease, because the presence of psoriatic arthritis is really independent of presenting psoriasis severity. Having said that, clearly, people with more severe skin disease are more likely to get psoriatic arthritis, but about 25% of people with psoriasis and mild disease have psoriatic arthritis. Ask every patient, and ask every visit. To me, that's the most important message I gave in the talk.

In order to address the issue of making it as easy as possible for dermatologists to at least ask about psoriatic arthritis, I spoke about what one could do. If one wants to do a mini physical exam, it's as easy as PSA, which is a algorithm developed by Dr Joseph Merola and his colleagues. P is pain in the joints. S is prolonged stiffness of greater than 30 minutes or inactivity. Or it could stand for swelling or sausage digging called dactylitis. The A is for inflammatory axial or spine involvement, which is back pain associated with stiffness that improves with activity.

Many dermatologists don't want to do that, so we developed an idiom, the International Dermatology Outcome Measures Group, that I founded and and president of, we developed an algorithm where the patient tells the doctor not only whether it's likely they have psoriatic arthritis, but whether they're in target. We do this with a free available test instruments that are available on the GRAPPA app for free. One of them is the PEST screening tool, which is a 5-question screening tool that if somebody answers 3 or more positive answers, it's likely they have psoriatic arthritis. Then there's the PsAID-12, which is a 12-question instrument which measures impact and symptoms of psoriatic arthritis, and there's a target. If the score is calculated, and if you're above that score, you're not in good control. These are available for free on any gizmo anybody could have: iPhone, iPad, Android, in many, many different languages.

We developed an idiom through a OMERACT process, highly rigorous process of developing and working with outcome measures, is when a patient comes or at a portal, as defined by their code, if their PEST score is 3 or more, or if they come with a rheumatologist's diagnosis of psoriatic arthritis, the patient, before they see the doctor, is given the PsAID. If the PsAID score is less than or equal to 4, then one can continue what one is doing, because the psoriatic arthritis is in acceptable control. If, however, the score is greater than 4, then one has to do something different or refer.

What we did as part of our quality project at Mount Sinai Union Square is we put both the PEST and the PsAID into our electronic medical record, which is Epic. When the patient opens their portal, or they're sitting in the
waiting room, if they have a psoriasis code, they are given the PEST and the PsAID. When the doctor opens up their chart, if the patient is not in good control, a yellow notice will come up, and it will say, "Your patient's PEST score of 3 or more indicates the patient may have psoriatic arthritis. If you are uncomfortable treating psoriatic arthritis, please refer this patient to our rheumatologist. Click here." It's a click away. You can't make it easier. The patient does the work, and the doctor should click the button. Then, if the if the PsAID score is greater than 4, then it also says, "Your patient's psoriatic arthritis may not be well controlled. Click here to get a rheumatology consult." I also maintain a list on that website of FDA-approved drugs for psoriatic arthritis.

How well does this work? We've submitted this to the Journal of Investigative Dermatology and presented it for the first time in my guest lectureship. In an 18-month period, we had 2341 psoriasis patients. Of those patients, the response rate to completing the PEST was almost 40%. Yes, it could be better, but it's incredibly good for a patient questionnaire. Of those patients, 25% of the patients had a PEST score of greater than or equal to 3, indicating they could have psoriatic arthritis. Almost all of them took the PsAID, and over the 18-month period, we found that using this algorithm, 62% of patients actually were in acceptable control.

This contrasts with an NPF non-interventional survey, where they just did the PEST and PsAID, and there was no action based on it, where only a third of the patients are in acceptable control. Using the PEST and the PsAID with an idiom developed algorithm, the patient does the work, and the doctor basically clicks a few buttons. With having the doctor made aware of the potential of psoriatic arthritis and potential for help in treating, 62% of patients were actually in target range, which I think is excellent for a dermatology practice.

Then I went over a comparative table with the domains of psoriatic arthritis, that is peripheral arthritis, skin and nail disease, axial disease, dactylitis, enthesitis, and with other factors, which may not be domains, but are confounding, such as inflammatory bowel disease, and I went over all of the FDA-approved treatments and which one does what, so that the audience could make a decision for their patient which would be an optimal choice. I also went over all the side effects from all of these treatments, too.

Then I discussed whether mute biologic use can actually decrease the risk of psoriatic arthritis. There's some hypothesis-generating data from registries, and I presented some of those, but we really don't have the answer to that yet.

I highlighted, for those folks who are interested in interdisciplinary teaching in an intimate and very high degree of interchange between KOLs and attendees, I suggested that they come to Masterclass in Dermatology, which is unique in that it is interdisciplinary teachers, in February 2025 in Sarasota next year. For the PAs and NPs of both rheumatology and dermatology training, we have for free attendance a meeting of similar quality November 1-3 at the Ritz Las Colinas in Dallas, Texas.

[Transcript has been edited for clarity.]