Case 3: 57-Year-Old Man With PsA

Anthony M. Turkiewicz, MD: Ana-Maria, you want to handle number 3 and we’ll wrap this up?

Ana-Maria Orbai, MD, MHS: My pleasure.

Anthony M. Turkiewicz, MD: Thank you. A 57-year-old gentleman presenting with severe plaque psoriasis as well as large joint arthritis, knees, intermediate involvement at left elbow, left ankle. Has had psoriasis since the age of 23, you’re looking at 30-plus years of psoriasis. Treated with topicals, had some improvement with topicals. He had no arthritis at the time of his diagnosis with initial psoriasis, but he got this arthritis fairly recently, 2 months prior to the visit that he got this asymmetric polyarthritis. Past medical and family history unremarkable. Had a screen test, and he then went on, he had some metabolic, CBC [complete blood count], and what not. He was started on methotrexate, 15 mg weekly, we’ll say it’s oral, some small amount of a physiologic dose of prednisone, 7.5 mg daily. He takes that for 2 months, has some clinical improvement. LFTs [liver function test] go up, that’s 4 times the upper limits of normal, right at the 120s for transaminases. They stopped the methotrexate, and they add sulfasalazine, 1 g BID [twice a day]. After 3 months of sulfasalazine, he had some mild improvement of the skin manifestations, but knee synovitis persisted, and CRP [c-reactive protein] still elevated.

We got into treatment on this one a little bit quicker, but impression, any recommended testing, and then what factors would perhaps play a role in the treatment options, and would you ever go down the methotrexate pathway again. Go ahead and give me your thoughts on that, Ana-Maria.

Ana-Maria Orbai, MD, MHS: This is a man with severe disease and possibly undertreated disease. It looks like he’s had severe plaque psoriasis for 30 years prior to this development of arthritis, and in my opinion, he’s developing this arthritis a bit late in his disease course. At age 57, I would definitely look for other types of arthritis, particularly gout, could this be pseudo gout? I would x-ray the large joints to look for calcifications and I would refer him to our musculoskeletal ultrasound clinic to make sure that I’m not missing erosions typical of gout, for example, or that I’m not missing entheseal changes typical of psoriatic arthritis. I would use a few modalities to be able to categorize this with more certainty, the inflammatory arthritis belonging to psoriatic disease.

The other piece could be that he’s been underdiagnosed with this arthritis and he’s had low levels of joint inflammation and we’re diagnosing it late altogether. He’s been using prednisone and methotrexate, and prednisone can I would say mask the joint disease. My concerns with this patient, and then he’s developing complications. He has liver function test elevation. First, I would confirm the type of arthritis that he has to be able to guide treatment. Second, I would diagnose his liver disease. Is he using concomitantly other hepatotoxic things? Is this Tylenol? Is this alcohol, or is it fatty liver associated with psoriatic disease? I would send him to an ultrasound, definitely would stop methotrexate. This would not be somebody I would rechallenge with methotrexate. I’m not sure I would have started sulfasalazine in the first place, and I would be surprised how sulfasalazine helps with his skin because that doesn’t usually happen. Assuming that he has inflammatory arthritis, which I think he has, psoriatic arthritis, then I would go right away to a biologic with 2 priorities: 1., to bring his disease activity down, and 2., to get him off of prednisone. These would be my 2 urgent objectives with this patient. I don’t think we necessarily have a specific indication for 1 biologic vs the other in this case. As Len said earlier, the options are wide open. He does need to get on something else.

Anthony M. Turkiewicz, MD: Assuming the liver calmed down a little bit, assuming his liver was from the methotrexate, which again, not knowing all the details, but it sounds like his baseline labs were fine. Someone gives him methotrexate; the liver goes up. Unless he’s starting to drink heavily, take Tylenol, it’s probably from the methotrexate, so I agree with you. Let’s say his liver was persistently high, would you maybe go down another MOA [mechanism of action] vs another, and it’s tough to know.

Leonard H. Calabrese, DO: I agree with Ana-Maria. First of all, getting 3x LFTs at 8 weeks on methotrexate, he’s got liver disease of some sort or he’s drinking heavily or something like that. He’s got cardiometabolic tendencies, and that’s a high priority. If he was going to get treated, he’s 57, you would avoid things like infliximab [Remicade], etc., and you’re wide open otherwise. That is a very significant finding and probably will represent a comorbidity that we’re going to have to deal with somewhere along the line.

Anthony M. Turkiewicz, MD: I think we’d all agree, no sense in rechallenging with it in that scenario.

Leonard H. Calabrese, DO: No way.

Ana-Maria Orbai, MD, MHS: No.

Anthony M. Turkiewicz, MD: Prednisone, treat by the prednisone 7.5 mg. We may not all admit it, we all sometimes have to play with it, but what are your thoughts on that, Sheetal? You’re looking at 7.5 mg daily for 2 months and then they say…so 5 months for this patient. That alone would have led you to go down not necessarily the sulfasalazine pathway, unless this patient just was absolutely refusing biologics. What are your thoughts on that, Sheetal, the oral prednisone?

Sheetal Desai, MD: Yes, we do avoid it as much as possible, but I know we all use it at some points. I will say that if I had to think of a number of patients that I truly felt had psoriasis, psoriatic arthritis, that I’ve started prednisone on, it’s on 1 hand how few times I’ve done it. Every time I’ve done it was because they needed some functionality and they couldn’t get their drug and they had to. We’ve always paid a price as we taper them off of it, that they had a lot worse manifestations of their disease with psoriasis. Yes, I try to avoid that. That’s a good amount of time for him to have been on the prednisone and I agree, it seems like most of the conventional synthetic DMARDS have already been tried and this is someone that you’re going to go to a biologic like Ana-Maria said. That’s what you’re leaning toward and I don’t see anything that would make me choose one biologic over another.

Anthony M. Turkiewicz, MD: Thank you for watching this HCPLive® Peer Exchange, and if you enjoyed the content, subscribe to the newsletters to receive upcoming peer exchanges and other great content in your inbox. Thank you.

Sheetal Desai, MD: Thank you. This was a lot of fun.

Leonard H. Calabrese, DO: Thank Anthony, he did a great job.

Ana-Maria Orbai, MD, MHS: Thank you.

Transcript Edited for Clarity