Management of psoriatic arthritis (PsA) can be notoriously complicated due to factors such as heterogeneity of disease manifestations and comorbidity considerations. Despite the emergence of promising new therapies, there remains considerable variation in quality of care from diagnosis through treatment and follow-up management.
Joseph F. Merola, MD, MMSc, a rheumatologist and dermatologist with the Division of Rheumatology, Inflammation, and Immunity and the Department of Dermatology at Brigham and Women’s Hospital, believes meeting the complexities of PsA requires a multidisciplinary approach to care involving rheumatologists and dermatologists.
As Dr. Merola points out, seamless coordination of PsA care is not easy to achieve. Rheumatologists can underestimate the importance of skin disease activity on patient quality of life and may feel less familiar with varied presentations of psoriasis, the differential diagnosis of skin eruptions and appropriate skin-directed therapies. Dermatologists, for their part, may not be familiar with joint examination and the differential diagnosis of articular disorders.
“By making a concerted effort to coordinate care, we can bring together different perspectives, sharpen treatment plans and improve the care of patients with psoriatic disease,” Dr. Merola said.
Specialized Care for Psoriatic and Connective Tissue Diseases
The Brigham’s Center for Skin and Related Musculoskeletal Diseases (SARM) is fulfilling Dr. Merola’s vision for coordinated care of psoriatic disease including PsA. It is one of only a handful of centers in the country to bring together rheumatologists and dermatologists to deliver comprehensive care for these conditions. Dr. Merola is the director of SARM, which also includes dermatologists Avery LaChance, MD, MPH, and Gabriela A. Cobos, MD.
“One of the novel things about SARM is that we not only have attending rheumatologists and dermatologists, but also have rheumatology fellows, dermatology residents and dermatology-rheumatology fellows, all in the same place at the same time,” he said.
According to Dr. Merola, the combined clinic model offers patients the convenience of “one-stop shopping.” They can go to a single site for all of the necessary education and support related to their disease, which often affects multiple systems, and receive timely access to a wider array of therapies, including systemic DMARDs.
SARM has also produced significant benefits for providers, who appreciate the collegial, cooperative clinic environment. Through fellowships (including the combined dermatology-rheumatology fellowship) trainees gain experience in the interdisciplinary management of various inflammatory skin and musculoskeletal diseases.
“The center also allows us to do some interesting research on this population of patients; for example, we study how patients with skin disease may transition to develop joint disease,” Dr. Merola said. “We can only do this if both of these specialties are present, so this model gives us an opportunity to do clinical research and even clinical trials in a really unique setting.”
A Psoriasis and Psoriatic Arthritis Registry
Along with Nancy A. Shadick, MD, MPH, and Michael E. Weinblatt, MD, both of the rheumatology division, Dr. Merola is also co-principal investigator of the Cohort for Psoriasis and Psoriatic Arthritis Registry (COPPAR), another rheumatology/dermatology collaboration at the Brigham. To date, this multi-sponsor, industry-funded registry has enrolled about 120 patients, toward a goal of enrolling 500 patients.
“The idea is to do very deep clinical phenotyping of these patients across the full spectrum of disease, from skin to joint disease, including looking at novel endpoints, like sleep disturbance, genital psoriasis and things that aren’t typically measured otherwise,” Dr. Merola said. “All of the patients contribute blood samples, and there are also optional skin biopsies to try to correlate with disease biology and ask some deeper questions.”
The registry, he added, encompasses extensive assessor activity measures as well as patient-reported outcomes and has a particular emphasis on how subjects progress from psoriasis to PsA.
Although COPPAR was formally launched just over a year ago, Dr. Merola and his colleagues have already collected multiple six-month and even one-year follow-up data. In light of the novel coronavirus pandemic, the investigators have inserted several questions about COVID in the registry as well.
“We’re asking subjects about their experience with having their psoriatic disease during COVID, managing their systemic immunosuppressive and immunomodulatory therapy during COVID, what they plan for vaccination, etc.,” Dr. Merola said. “I think it offers a new perspective on how these diseases are being handled in the era of COVID. That’s been interesting.”
Screening Psoriasis Patients for PsA
Research is another area in which rheumatology and dermatology come together at the Brigham. One recent study that gathered input from patients, physicians, industry partners and patient association representatives concluded that all patients in clinical trials for psoriasis should be screened for PsA and have their PsA symptoms measured. This work was led by Dr. Merola and Lourdes María Pérez Chada, MD, of the Brigham, together with outside leaders including Alice Gottlieb, MD, PhD, through collaboration with the International Dermatology Outcome Measures Group.
“This work is critical because we know that about 40 percent of psoriasis patients are undiagnosed for psoriatic arthritis,” Dr. Merola explained. “It highlights that we should not only screen patients and get them to the right therapy, but also see how some of our newer therapies and new mechanisms might impact the arthritis.”
Dr. Merola also brought up an initiative among combined centers examining PsA risk, transition and prevention through the PPACMAN consortium, of which the Brigham is a founding partner. Another initiative involves a partnership between PPACMAN and Sage Bionetworks, a nonprofit biomedical research and technology development organization, to create a smartphone app that patients can use to predict the development of PsA and measure disease activity remotely. Key centers in the validation of this novel work have included New York University, the University of Pennsylvania and the Brigham.
“We need a combined clinic to get all the right parties together to answer important questions and do this research, and we need registries like COPPAR to get the samples to find out who is at risk and what the potential biomarkers are for the development of psoriatic arthritis,” Dr. Merola concluded. “These interdisciplinary, collaborative endeavors are really helping us to move forward in our understanding of the disease and to advance treatments.”