Finding the PsA patient: the challenges of early diagnosis
Dr Arvind Kaul, Consultant Rheumatologist, St. George’s University of London talks about the challenges of an initial diagnosis in PsA and how the Six Domains can help spot signs early, which is key to ensuring effective management of this chronic condition.
Diagnosing Psoriatic Arthritis (PsA) is challenging. The condition can be subtle, ranging from undetected asymptomatic tendinopathy, unattributed mild tendinopathic pain such as the Achilles tendon or plantar fasciitis for years, to rapidly progressive severe erosive disease. The common PsA symptoms of joint pain and fatigue are commonly seen in other diseases and are not always viewed as major discriminatory findings. The lack of a diagnostic blood test means that patients, and doctors may attribute these symptoms to age or “wear and tear” without putting the patients Psoriasis or Family History of Psoriasis into proper context.
Patients are often reassured by the normal blood tests found when investigating PsA yet disappointed the tests don’t explain their symptoms. This often turns to surprise when their physician links their obvious biomarker – Psoriasis – to the joint pains. While healthcare professionals in Rheumatology will detect physical signs of arthritis including swelling and pain, many physicians and most patients will be less aware of the multiple domains which PsA affects, including skin, nails, enthesis, the spine and joints. Nor are the multiple associations of Psoriasis including premature cardiovascular disease, Atrial Fibrillation, hypertension, aortic inflammatory change and its psychological impact always well recognised in clinical practice. As a result, patients often live with PsA for many years before receiving a diagnosis and as a result, may receive treatment for their condition much later than they should.
Unfortunately, there is strong evidence that delay in diagnosis and treatment of PsA not only leads to permanent joint damage and restriction, but also reduced efficacy of therapy. Diagnostic delay contributes to higher societal and healthcare costs and greater work disability and much less likelihood of patients living a “normal” life, both emotionally and physically.
In clinical practice, a clear indicator of PsA are the GRAPPA Six Domains: nail disease, skin disease, peripheral arthritis, enthesitis, dactylitis and axial disease. Identifying these domains can play a huge role in the initial diagnosis and ongoing management of the condition. Patients typically present with a combination of the domains, and by using our knowledge of these, we are can move towards a more individualised, bespoke treatment plan for each patient. An individual holistic approach to PsA is the best way to achieve the optimum outcome for the patient.
Co-working between Dermatology and Rheumatology avoids duplication of tests and appointments and enhances the patient experience. An emphasis on combined working makes it more likely the patient will receive the right care and treatment at the right time. Beyond this, educating the healthcare community about PsA is becoming easier through evidence-based tools such as GRAPPA which are increasingly being used in clinical practice.
Although there is still more to be done to ‘find the PsA patient’ early, the progress which has been made so far has been spectacular. Our management of PsA was once based on utilising care pathways from Rheumatoid Arthritis. We now understand PsA has distinct attributes and mechanisms to other arthritides which require the specific treatment pathways described in the GRAPPA Six Domains. We have entered a very exciting era in the holistic management of PsA and I am confident we can ensure even better outcomes for patients over the next decade.