Abstract
Background:
Psoriatic arthritis (PsA) is a chronic inflammatory condition associated with psoriasis. The common clinical features of PsA include peripheral arthritis, dactylitis, enthesitis, spondylitis, skin and nail disease
1
. Considering the heterogeneous course of disease and the different patient characteristics, there is a need to standardize management of PsA patients. At present, no established guidelines are available on PsA care pathway in Saudi Arabia.
Objectives:
To provide consensus-based guidance to all Saudi health care providers (HCPs) on the management of PsA patients including referral pathway, definition of remission and treat-to-target approach.
Methods:
A Delphi technique was used to understand PsA patient care pathway. In first step, a targeted literature review was conducted and a survey questionnaire including 16 questions was developed to explore PsA patient journey. In second step, this questionnaire was submitted to 127 HCPs and 33 of them provided their response. In third step, a panel of 12 experts including 10 rheumatologists, 1 dermatologist and 1 general physician reviewed the available evidence along with survey results to align on final recommendations.
Results:
The most common management guidelines recommended for PsA were European League against Rheumatism (EULAR, 100% agreed) and American College of Rheumatology (ACR, 100% agreed). Psoriasis Epidemiology Screening Tool (PEST) was recommended by 67% of experts as validated screening tool for PsA in dermatology clinic. The laboratory investigations included were C-reactive protein (CRP, 100%), erythrocyte sedimentation rate (ESR, 100%), complete blood count (92%), urea and creatinine (92%), liver function (92%), rheumatoid factor (56%) and X-ray of affected joints (75%). For patients with additional symptoms of back pain, X-ray of sacroiliac joints and human leukocyte antigen B27 (HLA-B27) test to be included. Only rheumatologists should recommend a magnetic resonance imaging based on the individual clinical picture. The agreement criteria for HCPs for referring patient to a rheumatologist were presence of psoriasis (100%) and one of the following features: dactylitis [100%], joint pain [100%], arthritis [100%], nail dystrophy [91%]. Patient with active arthritis should be referred to rheumatologist within 4 weeks. The referral pathway agreed by the experts for PsA patients is presented in Figure 1. Majority of experts (57%) defined clinical remission as absence of disease activity in all facets of disease assessed using the disease activity in psoriatic arthritis (DAPSA) or minimal disease activity (MDA) index. For treat-to-target, 71% of experts agreed on EULAR recommendations
2
. For remission and treat-to-target, experts identified a need for more clear definition.
Conclusion:
This expert consensus aimed to provide guidance to Saudi HCPs on standardizing diagnosis and care of PsA patients. Most experts recommended PEST as validated screening tool for PsA along with laboratory investigations such as CRP, ESR, X-ray, etc. Referral to a rheumatologist should be considered for patient with presence of psoriasis and one of the other defining features for PsA. There is a need for more clear definition of remission and treat-to-target.
References:
[1]Ogdie A, et al. Rheum Dis Clin North Am. 2015;41(4):545–568.
[2]Gossec L, et al. Ann Rheum Dis. 2020;79:700–712.
Figure 1.
Referral pathway for psoriatic arthritis patients CRP: C-reactive protein; ESR: Erythrocyte sedimentation rate; CBC: Complete blood count; HLA-B27: Human leukocyte antigen B27; PEST: Psoriasis Epidemiology Screening Tool
Acknowledgements:
This project was supported by Novartis Saudi Ltd., Saudi Arabia and the Saudi Society for Rheumatology. We would also like to thank Dr. Xenofon Baraliakos for his support.
Disclosure of Interests:
Hanan Alrayes: None declared., Mansour Alazmi Speakers bureau: Pfizer, Abbvie, Khaled Alderaan: None declared., Mushabab Alghamdi: None declared., Nayef Alghanim: None declared., Ahmed Alhazmi: None declared., Nadeer Alkhadhrawi: None declared., Mohammad Almohideb Speakers bureau: Novartis, Abbvie, Celgene, Lilly, Jansen and Sanofi, Grant/research support from: Sanofi and Abbvie, Suzan Attar Speakers bureau: Lectures in symposium about different diseases in rheumatology and management, Grant/research support from: Research in recruiting patient, Zyad ahmed Alzahrani Speakers bureau: Pfizer, Novartis, MSD, Janssen, Abbvie, Lilly, Consultant of: Pfizer, Novartis, MSD, Janssen, Abbvie, Lilly, Mohamed Bedaiwi: None declared., Nancy Zakaria Employee of: Novartis, Hussein Halabi: None declared.