A diagnosis of any rheumatic disease, and especially psoriatic arthritis (PsA), can throw patients’ lives off the rails. They are enjoying outdoor activities, time with the family, regular vacations, and then “Wham!” They have to start thinking in advance about every activity they have planned, often deciding whether or not it’s worth the risk of another day or week in pain. It can be overwhelming and emotionally exhausting for our patients, and a difficult part of our job rebuilding their health and confidence so that they can once again embrace life instead of fearing it.
Anthony is a recent patient of mine whose life had unfortunately taken a turn for worse before I met him. He is an exquisitely kind gentleman who was diagnosed with PsA in his early 30s. I didn’t meet him within our practice until his early 60s. Anthony has been married for over 30 years, had been a successful business owner before recently retiring, a father of 3 daughters, and a grandfather of 2 boys and a girl. When he first came to see us, he told us that he was preparing to marry off his last daughter within a year.
At our initial visit, Anthony demonstrated several of the hallmark features of PsA, including enthesitis, tendinitis, low back pain, nail pitting, and psoriasis of the scalp, elbows, and knees. He also had multiple accompanying comorbidities such as depression, uveitis, elevated liver function (ie, fatty liver disease), hypertension, hyperlipidemia, and cardiovascular disease. Due to his PsA, he had already undergone multiple joint replacement surgeries involving his right shoulder, hip, and knee. Clearly, this was not a patient in the best of health.
When I took over Anthony’s care, his list of medications included etanercept 50 mg subQ once a week, prednisone 10 mg a day, prednisolone acetate ophthalmic 1% solution 1-2 drops in the right eye 2-4 times daily, metoprolol 50 mg daily, lisinopril 10 mg daily, atorvastatin 10 mg daily, daily low-dose aspirin, and daily vitamin D3 2000 units. His history in rheumatology included failed trials of infliximab (infusion reaction), adalimumab (unsafe elevations in liver function), methotrexate (also related to liver function issues), certolizumab (lack of efficacy), and leflunomide (again, liver function issues).
Anthony told me at our initial meeting that he still suffered from flares related to uveitis despite his daily prednisone. He also told me had been taking rescue methylprednisolone dose packs several times a month. Anthony was currently taking etanercept as that was the only medication he claimed ever worked to help control his pain, although there was still significant swelling apparent. I aspirated 90 cc of inflammatory fluid from his left knee at this initial visit.
After hearing of his health-related issues, I asked Anthony about his activities of daily living. What did he enjoy about life? Where was he struggling? It’s these personal connections that can often serve as the linchpin to building trust with our patients and are crucial to include in initial discussions.
Anthony told me he had not recently been seeing much of his grandchildren, which typically gave him so much joy. He feared that he wouldn’t be able to walk his youngest daughter down the aisle at her wedding in a few months, much less join her on the dance floor. He was practically in tears by now. He also told me that he was arguing more and more frequently with his wife because she was “worried about his health,” and he didn’t want her to get so worked up over him. He added that he had gained 20 pounds in the last 3-4 months and really wasn’t motivated to do much of anything.
By now, warning bells were going off in my head. All of these issues were clear signs of depression. I knew from his medical record that Anthony had a history of depression, so it wasn’t as delicate a conversation as it might otherwise have been. I suggested to Anthony that he might want to see a local therapist, and he agreed it would be worthwhile. He soon started on duloxetine 30 mg daily, upped within a week to 60 mg. I thought this would help both his mood and pain.
That was one initial hurdle overcome. Now it was time to address his arthritis. As noted earlier, Anthony’s disease was very poorly controlled, with multiple areas of enthesitis and tendinitis. His psoriasis, however, was fairly well controlled. Because of his medication history and pattern of repeated biologic failures, it was a tricky call. It was obvious that etanercept wasn’t the answer, but what was the best choice now? He had not had any better success with a previous trial of secukinumab, an interleukin-17 inhibitor, than previous tumor necrosis factor (TNF) inhibitors, so I decided to suggest a switch to golimumab, the only TNF inhibitor Anthony had not previously tried. Anthony was skeptical, having been down this road many times where he had gotten his hopes up only to see them quickly dashed. While we waited for his lab work to return, Anthony continued on etanercept but said he would consider a switch to golimumab.
Two weeks later, Anthony was back for his initial follow up. His mood had improved, and he said he recently spent several hours with his grandchildren over the preceding weekend. His lab work showed elevated inflammatory markers and mildly elevated alanine transaminase and aspartate transaminase levels. Hepatitis B/C and QuantiFERON Gold screens were all negative. Anthony received his first golimumab infusion later that day with plans to return for follow-up after his third infusion. He was instructed to call if he had any problems or concerns prior to that scheduled visit.
I heard nothing from Anthony so assumed everything was going well as his appointment date neared. Fortunately, it was. He virtually danced into my office he was so happy. The golimumab infusions and duloxetine had had a rapid, remarkable effect on his physical function and emotional stability. He told me that he was now confident he would be able to dance at his daughter’s wedding. Anthony’s lab results showed improvement as well, although his inflammatory markers were still mildly elevated. His liver function, however, had normalized. There was mild enthesitis upon physical exam, but this had improved greatly from Anthony’s previous visit. Based upon these findings, I added sulfasalazine 500 mg twice daily to his regimen and decreased the prednisone to 5 mg daily, with plans to hopefully increase the sulfasalazine to 1000 mg daily and stop the prednisone entirely. I asked Anthony to get a new set of labs in a month, and every 2-3 months thereafter.
At our next follow-up visit, Anthony was weeks away from his daughter’s wedding. Happily, things continued to progress well. His most recent labs were completely normal, and he told me he was pain free. There had been no recent flares of his uveitis. Basically, his life was back on track. He was so grateful that he would be able to give his daughter away at her wedding and celebrate this important family milestone.
Of course, due to the chronicity of PsA, it is likely that we’ll need to continue to tweak Anthony’s treatment at some point in the future, but it was so rewarding to be able to see him looking forward to one of the big milestones in his life. On the day of his daughter’s wedding, while Anthony danced the night away, I lifted a glass from my home as congratulations. For him and for me.
AUTHOR PROFILE: Nancy Eisenberger, MSN, APRN, FNP-C, is a nurse practitioner at Arthritis, Rheumatic and Back Disease Associates in Voorhees, NJ, and a member at large on the Rheumatology Nurses Society Board of Directors.
Participants will receive 2.75 hours of continuing nursing contact hours, including 2.0 pharmacotherapeutic contact hours, by completing the education in our course:
Rheumatology Nurse Practice: Managing the Common Comorbidities of Psoriatic Arthritis