Michele M Cerra, MSN, FNP-C

 In the start of early 2020 we did things different at Duke in our practice because patients weren’t afraid to change therapies or start new therapies or even continue their therapy. How has the pandemic affected you as far as keeping patients on drug and compliant, starting new medications and seeing them in clinic, and then tell us about your mix of video, telemed [telemedicine] to in person visits?

It’s been a challenging time. In the beginning, we had a lot of education for our patients to let them know that from the data we had from New York, places like NYU [New York University], Columbia, that it was safe to stay on medication. It was better to have inflammation controlled than your body trying to fight the disease and then trying to fight COVID-19. Once we got our patients educated enough on that fact, infusion went on as always. We didn’t miss a beat. If you weren’t coming in for an infusion, then we did a lot of video visits. They must come in at least every 6 months for a real appointment because you must touch patients. There’s no question. We can educate patients though and change medications on a video visit, I thought that was helpful. I’m glad that we had that option because it’s not safe to bring in people. Not everybody is vaccinated. With omicron especially patients are getting sick, even with 3 vaccines. We’re going to keep patients apart as much as possible, but patients are sticking with their medication because the data is out there, and we use evidence-based medicine and educate our patients and have good patients.

For the first 2 weeks of the pandemic, we were at home of course, just getting telemed [telemedicine] set up because we didn’t use it in our practice before the pandemic, which now I see was unfortunate. Once we got telemed running, I was 3 days in person in the office. We continued to see patients and they were coming in and then it was a wonderful day at home with telemed [telemedicine] up until June 1st, 2021. Duke [University] said, “OK, we’re all going back into clinic,” when we thought the numbers were going to go down and stay down. What I elected to do in June was I wanted to keep at least a half of day at clinic for my patients who are stable, and I could see them every 6 months in person but do some telemed [telemedicine]. Telemed [telemedicine] has become an important part of my practice and I will continue to utilize that. What percentage are you doing telemed [telemedicine] versus in-person visits?

Currently, the only people I’m letting in the office are people who need an injection or are coming in for infusions. Everybody else, because the numbers have been terrible, we have been doing video visits or phone visits if they can do a video just for the protection of our infusion patients and our other immunocompromised patients.

I will say that our infusion suite has been busy since the beginning of the pandemic. We’re fortunate to have individual bays and private rooms where the door slides and they’re soundproof and patients don’t have to worry about sharing germs, but we are just so backed up, continue to be backed up with infusions. So patients really were not afraid to come in during the pandemic to get their infusion. The same for you that you’ve experienced, right?

Yes. Once they were educated and knew that it was safer for them to be in control, we never missed a beat which is great. The only thing certain if somebody was getting a subq [subcutaneous injection] in the office we would go out to the car to make it more comfortable for a few of our medications that we use in psoriatic arthritis [PsA]. It’s a simple injection but other than that we try to keep patients as safe as possible. We don’t have the advantage of individual rooms. We have a big infusion suite. We had to decrease our number of chairs to give proper spacing, but we ran longer hours. We did everything we needed to do to make sure that everybody was accommodated.

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Before closing out their discussion on psoriatic arthritis management, two experts consider how the COVID-19 pandemic has affected their practice.

Managing PsA During the COVID-19 Pandemic

Do you have any practice protocols within your practice to increase compliance? For us at Duke [Duke University, Raleigh, North Carolina] we use nurse triage, which I’m very thankful to have. We have nurses that answer the phone [and] answer patient questions. [A] patient could be flaring and need to get an appointment for a joint injection, medication, maybe they’re not sure. An adverse effect, or it’s not effective. The nurses know they have practice protocols whether it's making them come in for lab work or a visit or just helping them to get connected to the pharmacy as far as getting drug. Do you have any specific protocols in place?

Yes. We do the same thing. Also, if patients are going to use subcutaneous medications,most of the companies have programs that they’ll send a nurse to the house.

Right now, with COVID-19, they’re doing it more on the phone or virtually, but it does help with compliance and it makes people feel special because they have us at the office and they also have somebody else they could call when they have a problem or question.

You see patients in 6 weeks if they’re started on [a] new drug. That’s wonderful. I wish I had more time to do that but what I do have is 1 of the other NPs [nurse practitioner’s] in the practice see them while I’m in the clinic and I can peek in on the patient. As far as patients who have been on [the] drug and are doing well, how often do you see them back in clinic for follow-up?

Every 3 months. I like to keep an eye on making sure that they’re staying adherent with their medications and if they don’t have any questions or new symptoms that they haven’t noticed but I’ll notice when I examine them. I know some people with psoriatic arthritis [PsA] who will go longer but 3 months is appropriate for my patients.

That’s our practice protocol. At Duke we see patients every 12 weeks and then for patients who are stable maybe every 4 to 6 months with the understanding that if they think they’re flaring or having issues they need to come in sooner.

During the pandemic or in general because this is even difficult for me, how do you know your patients are filling their prescriptions because only occasionally will I get certain insurance companies [that] will send me a letter stating your patient hasn’t filled their drug since… it’s not all of them. So I’m not sure if my patients are refilling and staying on drug when they drop off and I don’t see them for 6 months, or they disappear for longer sometimes, but then occasionally I get a request, they want a refill.

My triage department patients can’t get medicine filled without having their labs done. They’ll send it to immediately and say this patient’s requesting this, they haven’t been in in X amount of time, and we’ll set them up with a video or phone visit that day if that’s the case. The other thing in our EHR [electronic health record] I could look at all the pharmacies and see when my patients filled their medication and based on their request when it was last filled. This helps me understand, but if they’re not going to take their medicine, they’re not going to, but I will call them up, educate them, get them in video visit and find out what their concerns are. See if they want to do something different if they’re not going to take the medicine that they were taking. It’s a challenge. Also, we’re finding out that they were sick or something else and it’s something that we should know about, so keeping up with this is important.

Sometimes they’ve lost their job, they’ve been laid off, or maybe it’s through a divorce separation they’ve lost their insurance or a death of the spouse. Sometimes we don’t know the reasoning, but I usually don’t know unless I get a letter from the insurance or the patients email me or send me a MyChart message. It is hard to track these patients and then they’re usually showing up or wanting to go back on drug if they stop when they’re crashing and burning and their disease is just so out of control. That’s why we need to bring them back in and educate. All that inflammation is going through your bloodstream causing coronary artery disease, fatty liver disease, anemia. It’s just reeling them back in and educating them.

And there’s lots of ways for us, if it’s a DMARD [disease-modifying anti-rheumatic drug], they could shop it around at different pharmacies if it’s a cost issue like that, they lost their jobs. Again, we could get them in the patient assistance programs if they’ve lost their jobs. Most of the big pharma companies have programs like that. Again, if we can pick up on this it’s great that we can help our patients continue to keep their inflammation in control.

Sometimes just the GoodRx card. I know we get those in our practice. Some patients they’ll even say I might have Medicare or commercial insurance but sometimes I say don’t even run it just use the GoodRx card and their drugs they can get a lot of cheaper. That’s kind of crazy [because] you would think insurance would cover me, but normally GoodRx they can get it a lot cheaper.

Shared insight on technical processes and protocols used to manage patients with psoriatic arthritis, including those for prescription fulfillment.

Practice and Prescription Protocols for PsA

 What are some of the reasons for low rates of treatment compliance in our patients? We’ve touched on a few already. What are you seeing in your practice in your area as far as compliance to treatment and barriers to that?

Some of the barriers have to do with denial as I said earlier. They can’t accept their diseases yet. Other times it’s my younger people. They don’t want to be different. Why do I need medicine? Why do I have to give myself the injection? Why do I have to get an infusion or take these pills? Until they get bad enough where they have x-ray changes, or it’s getting in the way of their activities of daily living, that’s when we can see it. It’s interesting. I like to get my patients in for infusions often because I know they’re staying adherent to their medications and I have routine with patients who are afraid of treatment. I take them for a tour of the infusion suite. They happen to see it’s not the worst place in the world. There [are] people of all ages. We have 6 offices and all of them have infusion. They see there’s at least 10 people sitting in a room and laughing and not feeling ill from medication, so that’s something that I find helps with patients that you’re concerned if they’re going to be adherent or not to their medication.

 I agree with the compliance as far as IV [intravenous] infusion. We know our patients. You see the personality type or they’re afraid. They’re needle phobic and they don’t want to give themselves an injection, or they liked this about taking their methotrexate. They take few holidays, they’re traveling, or in our patients who are trying to get pregnant. But I agree. I take them over to our infusion suite. We have 1 at each of our clinics and if 1 room is empty, I take them in. They could watch TV, a nice comfortable recliner, tell them you know the nurses here very well. I try to introduce them. It gives them reassurance and they see other patients as they’re walking by who are getting infusions it helps as far as keeping them on drug. Also, with disease state awareness it’s important. I use up to date ACR [American College of Rheumatology] handouts. I have them all in my room and patients while they’re waiting for me can start reading. I also have some posters I like to put in my room with psoriatic arthritis [PsA] and it has a picture of a female and all the different areas of her body that can be affected. I say to them each time you come in I want you to look at that and if you think you’re having some symptom, maybe it’s in the gut or in your eye or in your spine, I need to know about that so we can manage it and you can feel better and continue to have a good quality of life and no problems sleeping and going to do your job and being with your family.

A brief overview on the drivers of noncompliance and treatment adherence in patients with psoriatic arthritis.

PsA: Identifying Drivers of Noncompliance

 How about patient-provider relationships and the importance of patients remaining compliant and staying on drugs? It’s important for me to have the patient a part of the decision process when it comes to drugs. Some of our patients will say, “Tell me what you think.” Then we have our other patients who tell me tell me the bad things that are going to happen to me when I start this medication. They see all these commercials on TV that it gives them all these adverse effects. If I had to go on some of them, I’d question the need for it and the importance of it. But having the patients in that decision process, they want to know how your other patients are doing on that medication. It gives them reassurance for compliance. Look at that patient as a whole and ask them, “What are your goals? What would you like to get out of this visit? Where would you like to be?” Most patients want to be who they were before they were diagnosed with psoriatic arthritis. Let the patients who want it to be part of that decision-making as far as their drugs and PTOT [physical therapy and occupational therapy]. Encourage anti-inflammatory diets—if it’s white it’s not right: sugars, potatoes, carbohydrates. We know that a lot of inflammation in the gut is driving our autoimmune diseases. Do you do anything different in your practice? I wish we had a dietitian on our team who we could send our patients to because we know they end up with obesity and have nonalcoholic fatty liver disease.

 Yes, I encourage the Mediterranean diet because it’s an easy diet. I tell my patients about that.

 I use handouts with my patients, and then I refer them. The interesting thing is that a lot of insurance companies will cover a dietitian visit. Some patients don’t know that. It’s helpful to get our patients to a dietitian, especially if they’re obese or have poor eating habits like some of our younger people do.

 I didn’t experience any pushback from many patients during the pandemic as far as changing mechanism of action with my biologic or therapy. For our patients with psoriatic arthritis, we have long-term relationships with these patients; they trust us. I didn’t experience much pushback when I needed to add on therapy or change therapy. How about you?

 I had the same experience. If patients were hurting, then most of them would do whatever I recommended for them to do because we did have that trust relationship. There were a couple of patients who did stop their medications and did poorly. I could count them on my hands. I see 100 patients a week, so there weren’t many patients who didn’t do what we needed them to do to keep them in good control.

 I found that the patients who didn’t want to or were low resistance to change therapies were the ones emailing all the time or calling for prednisone. We had to get into that discussion about prednisone also being an immunosuppressant, so it’s not good to take it during the pandemic if you did get COVID-19.

 With my patients, I’d give them an analogy: think of prednisone as affecting your entire immune system and suppressing it. Our other medications are very targeted and suppress only a portion of our immune system. It’s a rudimentary way to explain it, but once I did that a lot of them understood that their medications were safer than taking prednisone. They understood that concept. But otherwise, every 6 weeks, people who weren’t taking their medicines were calling for a Medrol dose pack.

 That’s an excellent analogy. I’ll need to use that: prednisone suppresses your whole body, whereas we have targeted therapies toward different cytokines and proteins. Thank you for that.

Expert perspectives on the importance of establishing good patient-provider relationships while managing psoriatic arthritis.

Michele M Cerra, MSN, FNP-C

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