Making the Whole Patient Better

I have been caring for KN, a 57-year-old woman with psoriatic arthritis (PsA) for approximately 9 months. When she initially presented to our office, she had oligoarthritis, sacroiliitis, and nail involvement. Her medication history included an inadequate response to adalimumab and infliximab. Her medical history included metabolic syndrome, obesity, osteoporosis, depression, and a strong family history of coronary artery disease on her father’s side.

Upon presentation, KN complained of significant hand and foot pain and swelling, along with lower back pain that was at its worst in the early morning. She told me that it typically took 3-4 hours for her morning stiffness to improve enough to begin her day. KN also had extensive psoriasis covering approximately 20% of her body. Due to her visible skin disease, she had low self-esteem and avoided most social situations.

In addition, KN was the primary caretaker for her 8-year-old daughter with special needs, requiring a significant battery of medical appointments and school activities. These day-to-day responsibilities, along with KN’s active PsA, not surprisingly led to high stress levels, low energy, and a lack of general enjoyment of life.

I was fortunate that KN was open with her personal struggles. There are many patients for whom it takes months to build trust and get to open up about their stress-related challenges. Since KN was willing to share her issues with me from the start, it helped us develop a holistic plan of care.

We first focused on the management of her active PsA, reviewing several options before deciding on secukinumab. KN received her initial loading dose of 300 mg and began to see immediate benefits. Her skin became less itchy, and her joint pain and stiffness both began to alleviate.

When she returned to my office 6 weeks later, her general mood seemed lighter, and she admitted to feeling more optimistic about the future. Needless to say, we were both pleased with her rapid progress and looked forward to further improvements in the future.

Now that her PsA symptoms have improved, we have next turned to getting a handle on KN’s many comorbidities. We recently talked about the prevalence of medical comorbidities in patients with PsA—studies have shown that more than 50% of patients with PsA have more than one comorbidity that impacts their health and quality of life.1 In my mind, KN’s most significant comorbidity was her cardiovascular disease (CVD) and risk of myocardial infarction (which terminated the life of her father at age 51).

Prevention of cardiovascular disease among patients with PsA is vital due to its potential for significant morbidity and mortality. Systemic inflammation is thought to contribute to the high prevalence of cardiovascular events in patients with PsA. Therefore, treatment of joint pain may in itself reduce a patient’s risk of CVD. To get a sense of KN’s overall risk of CVD, I ordered baseline serum lipid testing and obtained her blood pressure so that we could calculate a cardiovascular risk score. It should be noted that risk stratification measures such as the Framingham Risk Score may underestimate the true risk of CVD in patients with PsA.

The second comorbidity I discussed with KN was her obesity. With a baseline BMI of 33.2, KN fell into the obese category. While there are multiple benefits for our overweight and obese patients related to weight loss, studies have shown that weight loss can specifically improve the efficacy of PsA medications and decrease the risk of developing cardiovascular disease and diabetes. KN and I discussed the data, and she agreed to be referred to our hospital’s weight loss center for additional assistance. In the meantime, she said she would give the Mediterranean diet (primarily plant-based foods) a try and attempt to amp up her weekly exercise regimen.

Finally, I introduced perhaps the most difficult comorbidity to discuss with our patients—depression. The medical literature has shown that patients with PsA have higher rates of anxiety and depression than patients with psoriasis alone.3 Depression can not only impact quality of life but has a negative impact on drug adherence and patient motivation to adopt a healthy lifestyle.2 Although KN’s mood had certainly improved after the initiation of secukinumab, she said that she still felt sad at times and agreed to be referred to a social worker to discuss additional means of help with her daily moods.

KN’s improvements in pain and overall mood are a great start to help her regain the energy and motivation to care for herself. Addressing our patients most obvious symptoms of inflammatory disease is often only a start. It is vital that we educate and screen our patients for core comorbidities such as CVD and psychological disorders, and bring in additional healthcare experts with specific skills as necessary.

I am hopeful that KN will continue to improve and that she will become a healthier person as the months and years go by, although I will keep a close eye on signs of setbacks. It is rare to have a patient who continues on a straight line of improvement when multiple comorbidities need to be addressed. However, we can hope that by continued reinforcement and effective communication, we will keep these patients motivated to keep trying and reaching for that goal of optimal long-term health.

AUTHOR PROFILE:
Eileen J. Lydon, MA, RN, ANP-BC
Eileen Lydon works at the New York University Langone Orthopedic Hospital in New York, New York and is the Chapter Development Chair of the Rheumatology Nurses Society.

 

References
1. Ogdie A, Schwartzman S, Husni EM. Recognizing and managing comorbidities in psoriatic arthritis. Curr Opin Rheumatol. 2015;27(2):118-126.
2. Torre-Alonso JC, Carmona L, Moreno M, et al. Identification and management of comorbidity in psoriatic arthritis: evidence and expert based recommendations from a multidisciplinary panel from Spain. Rheumatology International. 2017;37(8):1239-1248.
3. Haddas A, Zisman D. Comorbidities in patients with psoriatic arthritis. Rambam Maiminides Med J. 2017;8(1):1-6.