Screening for Comorbidities Is Important to Guide Treatment Selection in PsA

Identifying important comorbidities and their effects on treatment selection may be beneficial during management of patients with PsA.

Comorbidities in patients with psoriatic arthritis (PsA) can affect the effectiveness of treatment, and therefore, screening for these comorbidities is important in the management of PsA, according to a review published in the Journal of Rheumatology.

Researchers conducted a systematic literature review to update the 2021 Group for Research and Assessment of Psoriatic Arthritis (GRAPPA) treatment recommendations regarding the management of patients with PsA and comorbidities. They assessed studies published from February to January 2021 and included 40 eligible papers of the 143 identified studies.

None of these 40 studies were randomized controlled trials; 21 were prospective cohort studies, 11 were retrospective cohort studies, 2 were case-control studies, 4 were before-and-after studies, and 2 were cross-sectional studies.

According to the literature, patients with PsA demonstrated increased prevalence of cardiovascular disease (CVD), obesity and metabolic syndrome, and liver disease, especially nonalcoholic steatohepatitis (NASH).

We hope that the recommendations from the comorbidity working group will assist clinicians in identifying important comorbidities and considering their effects on treatment selection.

Health care providers are recommended to screen any patient with PsA for cardiovascular risk factors and encourage a healthy weight to improve PsA disease activity and impact on response to treatment. Providers should routinely monitor liver function tests in patients with PsA receiving certain medications and assess for fatty liver disease before selecting therapies that might impact the liver.

Studies were limited about the prevalence of hepatitis B (HBV), hepatitis C (HCV), human immunodeficiency virus (HIV), and tuberculosis (TB) in patients with PsA compared with the general population. Certain immunomodulatory therapies used to treat PsA may impact untreated HBV, HCV, and HIV, so it is important for providers to screen patients for these infections before initiating treatment. Biologics, especially tumor necrosis factor inhibitors (TNFi), increase the risk of developing active TB infection in patients with PsA. Screening for active or latent TB infections prior to starting biologic therapy is important.

According to the literature review, patients with PsA receiving treatment with interleukin (IL)-17 inhibitors demonstrated increased risk for Candida infection, while those receiving TNFis often presented with more severe herpes zoster infections. Patients with PsA had higher rates of developing herpes zoster infections than the general population.

Given the heightened risk for infection in patients with PsA, providers must advocate for vaccinations against influenza, pneumonia, herpes zoster, COVID-19, tetanus, HBV, and hepatitis A.

Mood disorders, especially depression, are more prevalent among patients with PsA and predict reduced joint remission. Providers should refer patients with PsA to a mental health provider to address mood changes, as it may interfere with quality of life and increase likelihood of disability and loss of income.

Patients with PsA have a low risk of developing malignancies, with similar rates of malignancy as that in the general population. However, certain studies reported an increased risk for nonmelanoma skin cancer in patients with PsA receiving immunomodulatory medications.

Fibromyalgia, chronic pain, and/or central sensitization affects between 20% and 30% of patients with PsA vs 6% of the general population. Prompt diagnosis and management of fibromyalgia or central sensitization may improve patient response to therapy and quality of life.

Limitations of the review included the strength of data supporting treatment recommendations, which may have been limited by a small number of study participants, limited follow-up, and lack of clinical trial designs.

“There is much work to do to improve our understanding of how best to screen for, manage, and prevent comorbidities in patients with PsA,” the study authors said. “We hope that the recommendations from the comorbidity working group will assist clinicians in identifying important comorbidities and considering their effects on treatment selection.”

Disclosures: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

This article originally appeared on Rheumatology Advisor

References:

Campanholo CB, Maharaj AB, Corp N, et al. Management of psoriatic arthritis in patients with comorbidities: an updated literature review informing the 2021 GRAPPA treatment recommendations. J Rheumatol. Published online November 1, 2022. doi:10.3899/jrheum.220310