Biologics and Advanced Therapies in the Management of Psoriatic Arthritis - Episode 15
Anthony M. Turkiewicz, MD: Let’s talk about psoriatic arthritis specifically during this very unique year of the COVID-19 [coronavirus disease 2019] pandemic. Specifically, your practice in general. We’ll start with Steve, the dermatology side. Could you tell me about how your practice has changed during the pandemic, whether it’s patient flow or telemedicine and office therapies, can you walk us through that?
Steven R. Feldman, MD, PhD: Yes. The clinic has changed some. For 6 weeks we shut it down except for emergencies, but now we’ve reopened. In the reception room we block off some of the chairs. My clinics don’t have quite as many patients per unit time, so that patients aren’t on top of each other. But the clinic operation is pretty much back to normal. Patients are wearing masks. We have fewer visitors. Instead of walking into a room with an entourage of 5 medical students, I’ll have, at most, 1 with me at a time. We do some teledermatology, and as a dermatologist my guess is it’s probably easier to treat patients with psoriasis by teledermatology than it is to manage the rheumatologic aspects because I can look at their skin with a good camera if they have an iPhone.
I feel comfortable doing that. I’m not doing a lot of teledermatology because it does make me more like a rheumatologist. In other words, I can see fewer patients per hour, I don’t get to do simple procedures in the office that increase the revenue. Teledermatology is not going to be popular among dermatologists, but the patients seem to like it. Another thing that changed is that I find myself not worrying about tests that are of questionable value. For example, my nurses want a TB [tuberculosis] test to be done on the patient every year if the patients are on an IL-17 [interleukin-17] or IL-23 blocker. And I’m like, “No, we don’t need that anymore.” The risk of the patient going to the laboratory probably exceeds the benefit right now, and if a patient doesn’t have an annual TB test, I don’t feel so bad about that.
Anthony M. Turkiewicz, MD: That’s a great point. It’s funny because we deal with that as well, and it’s not CDC [Centers for Disease Control and Prevention]-driven, this is largely driven obviously by the payers. CDC says check before and then check as clinically appropriate. That’s a great example, and I concur with that.
Steven R. Feldman, MD, PhD: The other thing that comes up a lot is new classes of questions from the patients about how their disease impacts their COVID-19 risk, how their treatment impacts their COVID-19 risk. Immunization issues will come up. And basically, the psoriasis at least, probably has little to no impact on COVID-19. My treatments, the biologics have little to no influence. Maybe the benefit exceeds the risk. There are so few hard data to go on. There are no controlled trials, and if there is a change in risk, maybe you’re going to find a study, if you have a large enough sample size, that finds a statistically significant risk—but a clinically meaningful risk, I don’t think there is.
Anthony M. Turkiewicz, MD: Hillary, your thoughts in your clinic about COVID-19 and its impact.
Hillary E. Norton, MD: Yes, much like Steve, my actual practice patterns have not changed. Fortunately, we have the global rheumatology database now. We have ACR[American College of Rheumatology] guidelines to fall back on because those patient questions are coming in, in my office as well. They’re concerned about safety, they’re concerned about whether they can continue biologics. But as far as the practice itself, we’ve made some pretty drastic changes. Our doors have been open the entire time. Traffic did slow at the beginning when people were panicking, and we did more telemedicine then. But then the patients came back, and we have been busier than ever because patients want their infusions, they want their joint injections, they want to be seen in person. And it’s such an intense time. I’ve seen patients where this is the only time literally they have left their house in months. Other intense issues are coming up. Patients are struggling. They’re struggling to get their activity and exercise in. I think we’re hearing a whole different aspect of their health than we used to.
As far as my office, we don’t have a waiting room anymore. Their cars are the waiting room. We had to socially distance our infusion patients, so the waiting room is a second infusion suite now, and visitors aren’t allowed in. Everybody is masked, we take their temperature in the parking lot, all that. And now that our cases are rising, unfortunately, we’re starting to encourage more telemedicine again just to decrease traffic in the office over the winter. Patients do like telemedicine, so we’ll see where that goes. Interesting times for all of us.
Anthony M. Turkiewicz, MD: Absolutely. John, Hillary mentioned the ACR recommendation that had come out…has that impacted what you do? A lot of it was largely common sense to most of us. But how has the COVID-19 pandemic affected your clinic, John, and anything about the recommendations that you want to share?
John Tesser, MD: I agree with you, a lot of it was common sense and empirically derived recommendations. We shut the office in April and May except for infusions emergencies. We did all telemedicine. In June we reopened, and then the cases started to rise in Arizona. So in July and August into September, we basically saw new patients in the office, and we did return patients by telemedicine, continued the infusion patients, and then we reopened completely in mid-September, and we’ve been going that way. But I’m afraid, like my colleagues here, that the numbers are going up again, and I’m not sure how we’re going to deal with that. We’re doing all the necessary social distancing, and the masking, and not too many people coming into the office with their families. It’s been straightforward.
I had the feeling from the very beginning that this infection should be approached like any other infection. Our patients are at higher risk for more severe infectious complications, from any infection, if their systemic rheumatic disease with a high burden of inflammation is not controlled. Therefore, continuing their medications and keeping their immune systems in better check and balance, and having control over systemic inflammation, would give them a better chance in fighting off any new infection, including COVID-19. That had been my premise, and our practice pretty much observed that way. We have not stopped anyone’s therapies. Then the guidance came out, and it reaffirmed what my own angle on this was. I was happy about that, and exercising common sense precautions makes all the difference in the world.
I agree with Hillary that patients have been shut in. I’ve been amazed at how many of my patients have been of the opinion to social distance, wear masks, and none of this nonsense that we get from vocal and vociferous groups of people about objecting to all of that and making a political statement. I’ve been very happy that almost all of my patients have demonstrated none of that. But by shutting themselves in, they’ve been putting themselves at risk. I have found myself encouraging them to get out and get some walking in. It’s absolutely important. The cognitive benefits, the cardiovascular benefits, the immunologic benefits, the exercise and getting outdoors are immensely important, and I’ve been emphasizing that to patients. A lot of them had been doing some of that. Some of them needed encouraging, but it makes all the difference in the world, and it’s our responsibility to try and support them in all aspects of their quality of life in this regard.
Hillary E. Norton, MD: I agree with you, John. I’m talking to patients about walking more than ever, just being outdoors in nature, as well as the exercise benefit. We’re dealing with the mental aspect of health more than ever during the pandemic.
Anthony M. Turkiewicz, MD: We can’t emphasize that enough. In closing, first I’d like to thank all the panelists for a robust discussion that is very informative. We reviewed a lot this morning. Before we conclude, I’d like to get some final thoughts from the panelists, any general thoughts. Dr Feldman, we’ll start with you.
Steven R. Feldman, MD, PhD: I’d refer people who have an interest in this area to our National Psoriasis Foundation. The website is www.psoriasis.org. For people who have psoriatic disease, it’s a great way for them to learn about all their treatment options and to empower them in other ways to take good care of their health.
Hillary E. Norton, MD: Yes. I come back to the fact that this is still an under-recognized, underdiagnosed, and undertreated disease. It’s important for patients who have psoriasis and have joint pain to get evaluated by a rheumatologist. It’s a very heterogeneous disease, as we’ve covered today. This can present in so many different ways.
John Tesser, MD: I would agree with my colleagues, and I would recommend to any of the audience that if you want more detailed support, and information, and guidance on treatment, I’d refer you to the ACR/National Psoriasis Association guidelines for treating psoriatic arthritis. There are a lot of detailed recommendations there.
Anthony M. Turkiewicz, MD: I thank you all for participating, and thanks to the audience for watching this HCPLive® Peer Exchange. If you enjoyed the content, you can subscribe to the e-newsletters to continue to receive upcoming Peer Exchanges and other content. Thank you.
Transcript Edited for Clarity