Practice Perspectives on Optimal Patient Care in the Management of Psoriatic Arthritis - Episode 7

Considerations for Treatment Selection and Shared Decision-Making

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John Tesser, MD; Nehad Soloman, MD; and Jennifer Simpson, DNP, talk about the importance of shared decision-making in the treatment of psoriatic arthritis.

John Tesser, MD: How do you look at this, Jen, when you think about how you get oriented on a patient’s disease?

Jennifer Simpson, DNP: I take into account what I think the patient is going to be compliant with. Am I dealing with a young female who may want to plan a family? I’m not going to be thinking about putting that patient on a DMARD [disease-modifying anti-rheumatic drug] at that point. Methotrexate, leflunomide, and sulfasalazine aren’t going to be good options for them. Maybe looking more towards a biologic and most likely certolizumab. With a patient, if we were just looking at how active their disease is, if they have as you said, just a couple joints involved, maybe less than 3% body surface area from their psoriasis, I would use a DMARD with that patient. I’d start off with methotrexate barring they don’t have underlying liver dysfunction, kidney insufficiency, or cytopenias that I need to be concerned about.

But, if all their blood work is looking good initially and if they don’t have underlying gastrointestinal effects already and they’re a patient I’m either confident they’re not planning to have a family soon or are not within the childbearing age, then I’m definitely willing to start with a DMARD first. Patients tend to be compliant with an oral agent first. Especially methotrexate being only once a week patients do like that. And sometimes it is helpful from an insurance standpoint to start with a DMARD first. We do run into different variances with insurance where they’ll give us some pushback with starting straight off with a biologic. So there are slight variances and things we need to consider there.

You’ll definitely run across your patient who can’t take a pill for whatever reason, and they need to be on some type of injectable or infusible and that’s going to be another variable that we have to consider. And again, what are they going to be compliant with? I have definitely had my fair share of patients who had a needle phobia and want nothing to do with needles whatsoever. It’s all these different things that we have to be considering.

I definitely like to get my patients involved in this decision but everyone’s personality is different so it’s kind of just learning your patient’s personality and what they’re going to feel comfortable with. What has worked well for me when I’m having that conversation with the patient is here are the different steps we can take. What do you feel comfortable with? Can you see yourself giving yourself an injection? Are you OK with taking an oral medicine every day? How’s your stomach? Do you often have an intolerance to oral medication? And just letting them know there are options and that we do have different paths we can go down.

Some patients really want to be very involved in that decision. Some of them want to pick out, like hand-pick, what medicines they’re going to be on, while other patients just listen. They want to hear what you’re going to say, but then at the end, they’re just like, “I want you to decide what I’m going to do.” But I think it gets down to really getting their buy-in and them being a part of the conversation and being part of the decision. You’re going to get more compliance from them. They’re going to have buy-in. They’re going to feel like you care about their opinion on the matter. I think that being said, no matter what medication or treatment option we’re choosing, if they’ve not bought into it, if they’re going home and they’re not going to take it or not be honest with you about taking it or not, if they’re not taking it at all, it’s not going to do anything for them.

Setting those intentions and managing those expectations like what can they expect from a side effect standpoint? What can they expect from a monitoring standpoint? For some patients, you tell them you have to come in every 3 months for us to check blood work on you; sometimes that’s a limiting factor for some people. That they don’t care how great they’re going to feel, they don’t want to come every 3 months to have blood work drawn. So I think setting those expectations, managing them is a huge part of what we do to make sure that the patient is achieving the outcomes that we want them to achieve and that they are getting better functionality.

John Tesser, MD: Those are terrific points. There’s a term for that interaction where you are working with the patient to decide in the sense that they have the buy-in and they own the decision, that way they’ll be more adherent to therapy. It’s called shared decision-making. It’s a whole industry, in fact, and there’s a whole movement internationally of shared decision-makers to try and emphasize the process that’s involved.

This transcript has been edited for clarity.