When Treatment Guidelines Meet Clinical Practice

There are a number of treatment guidelines/recommendations available in nearly every disease state that are based on high-quality clinical evidence. These guidelines typically take many months to develop and require the input of dozens of the leading providers in a given therapeutic area. It’s a grueling, rigorous process.

While it’s important for all of us working in clinical practice to be aware of these guidelines, it is also important to realize that they aren’t intended to be pulled out with every patient interaction to ensure that the prescribed algorithm is followed to the letter. As is typically pointed out within these guidelines, they are only intended to be used as a roadmap; there are so many variables to our patients that we sometimes need to use our best clinical judgment and deviate from the recommendations to best serve every patient that comes through our door.
There are, however, times when we see a patient who seems to fit the guidelines’ blueprints precisely. These patients can serve as good tests to determine the clinical applicability of the expert recommendations in your practice.

I recently had a patient, MM, who allowed me to test the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) recommendations for the management of psoriasis and psoriatic arthritis (PsA).

MM was a 47-year-old male who first came to our office approximately 6 months ago to establish care. He had been diagnosed with psoriasis at age 33 and with PsA at age 37 by another rheumatology practice. At the time of his initial diagnosis, he presented with pain and stiffness of the right hip and bilateral ankles. His pain was fairly well controlled over the course of the subsequent decade with use of regular naproxen (the first step in the GRAPPA guidelines),1 and he only scheduled appointments with his rheumatologist once or twice over that entire period. To manage his psoriasis, he received periodic injections of triamcinolone, along with light therapy.

MM had both a maternal and paternal family history of psoriasis and PsA, and he was urged by his family to re-establish care with a rheumatologist after a decade of spotty appointments. Since several members of MM’s family were treated in our practice, it was a natural fit for him to join them as our patient.

Upon initial questioning, MM reported pain in his left wrist that necessitated a brace to lift heavy objects. He also noted recent pain and stiffness in his neck. An MRI showed some fluid in his left elbow. There were also psoriatic lesions present on the palm of both hands and his left leg. MM reported minimal morning stiffness and was generally satisfied with the relief he got from use of as-needed naproxen.

There were minimal additional medications in his record—only cholecalciferol (a type of vitamin D) and sildenafil.

Physical exam showed psoriasis on MM’s left 5th digit and left palm, and several lesions on his left lower extremity. He had decreased range of motion in his left wrist. There were no tender joints, enthesitis, or dactylitis. Labs results included negative anti-nuclear antibodies and anti-citric citrullinated proteins. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels were also normal.

Due to the lack of urgent red flags, our rheumatologist and MM mutually agreed to continue with the naproxen and follow-up in 1 year, or sooner if necessary.

Six months later, MM was back in our office for an urgent appointment. He had just retired from his job as a construction foreman and was now much more aware of his joint pain and stiffness. His neck and left wrist had both become worse to the point where even holding a coffee cup was difficult. Both of MM’s ankles were also stiff most of the day.

Upon further questioning, MM told me he wasn’t certain if his overall pain was worse or if he was just more aware of it since he wasn’t on his feet working most of the day. Regardless, he expressed frustration that these issues were getting in the way of his retirement plans to travel and participate in other activities that he enjoyed. His psoriasis remained under decent control with continued triamcinolone and light therapy, but he was ready for an escalation of therapy to manage his PsA symptoms.

The GRAPPA guidelines recommend the use of a biologic agent (TNF inhibitor or one of the interleukins) in patients with axial disease who are no longer responding to an NSAID such as naproxen.1 Consequently, it was an easy decision to recommend a biologic to MM. Being very knowledgeable about biologic options for the treatment of PsA due to his family’s history with the disease, MM readily agreed to try weekly etanercept.
I began by updating MM’s lab tests. He tested negative for tuberculosis, had been previously vaccinated for hepatitis, and was human leukocyte antigen positive (not surprising considering his family history). His ESR remained normal but his CRP had jumped to 35 mg/l (normal is 0-10 mg/l).
It’s been 1 month since we started MM on etanercept. While it’s too soon to determine any notable benefit, MM has reported some improvement in his neck pain and stiffness. In addition, the psoriatic lesions on his legs and palms are not as widespread.

Whether intentionally or not, MM’s case illustrates how consensus treatment recommendations can help guide treatment. Healthcare providers can lean on these recommendations in our discussions with those patients who fit a more classic/standard profile of PsA. While not every patient will neatly fit into any generic box of symptoms, it’s helpful to have a sense of these recommendations in the back of your mind as an added tool in the treatment decision making process.

 

AUTHOR PROFILE:
Linda Grinnell-Merrick, MS, NP-BC, is a board-certified nurse practitioner at the University of Rochester Medical Center in Rochester, New York, and the President of the Rheumatology Nurses Society.

 

Reference
1. Ortiz Z, Shea B, Suarez-Almazor ME, Moher D, Wells GA, Tugwell P. The efficacy of folic acid and folinic acid in reducing methotrexate gastrointestinal toxicity in rheumatoid arthritis. A metaanalysis of randomized controlled trials. J Rheumatol. 1998;25(1):36-43.