Psoriatic Arthritis Guidelines for Managing Comorbidities

Guidelines aimed at educating doctors about the need to screen patients with psoriatic arthritis for conditions that often accompany the disease are helping increase awareness that this chronic, inflammatory arthritis affects more than just skin and joints. The guidelines were drafted in 2014 to provide evidence that doctors need to be more aware that comorbidities for psoriatic arthritis have been underappreciated and underreported.

“What really is important is to treat the patient as a whole and to say there are associated conditions that are more common in people with psoriatic arthritis, and physicians treating these patients should be made aware,” explains Elaine Husni, MD, director of the Arthritis and Musculoskeletal Center at the Cleveland Clinic and head of the group that drafted the guidelines.  

Psoriatic arthritis is an autoimmune type of arthritis that affects as many as 30 percent of patients with the chronic skin condition psoriasis. Generally, the arthritis appears several years after the onset of psoriasis, although in some cases it can appear before or at the same time the skin condition begins. In addition to psoriasis’ red, scaly rash, symptoms of psoriatic arthritis include painful and swollen joints, morning stiffness, reduced range of motion and general fatigue.

Psoriatic arthritis is classified as a spondyloarthropathy, a group of diseases with overlapping features. The diseases usually involve the spine, pelvis (sacroiliac joint) and entheses (the locations where ligaments and tendons attach to bone). They may also be associated with a particular gene called HLA-B27. Other spondyloarthropathies include ankylosing spondylitis, enteropathic arthritis (arthritis that is linked to inflammatory bowel diseases) and reactive arthritis.

Dr. Husni says research revealed important information about broader health risks for patients in this group. Topping that list: cardiovascular disease, which the guidelines recommend all psoriatic arthritis patients be screened for.

“We now know that cardiovascular disease is more prevalent [than in the general population],” says Dr. Husni. Although a sedentary lifestyle, obesity or treatment with corticosteroids may contribute to the risk, she says there are clearly disease-specific factors that can lead to heart disease. “So that tells us it’s the disease itself,” she says.
 
The guidelines also recommend screening for inflammatory bowel disease, as well as ophthalmic conditions, such as uveitis, because studies show a likely link with these conditions as well. People might not think that eye inflammation is related to psoriatic arthritis, but if doctors are more aware of it patients will get help sooner and hopefully not suffer more damage. 
 
The guidelines also recommend patients be screened for obesity and diabetes. Furthermore, before starting a biologic or another immunosuppressant, it is recommended that patients get tested for infections like tuberculosis, HIV and hepatitis B and C – especially if they have additional risk factors.

Dr. Husni says while the guidelines include information on what medications are used to treat the various comorbidities, they don’t recommend particular treatments because there are a range of options and a variety of different types of doctors who might manage them. Hopefully knowing what to look out for will help doctors and patients understand what symptoms could be related to psoriatic arthritis instead of thinking it is something else. This way, patients can also tell their rheumatologist about their symptoms and get better comprehensive treatment. 

Many rheumatologists may already be aware of these comorbidities, but guidelines and an organized approach are helpful, especially when other types of doctors are overseeing patient care. It’s also important to understand that comorbidities can vary, depending on which of the five subtypes of psoriatic arthritis a patient has.