A patient presented to my office as a new patient, sent because of elbow pain. After careful history taking and an examination of the elbow, it was determined that she had what is better known as “Tennis elbow”, or lateral epicondylitis. Further examination, revealed what we call dactylitis (sausage digit, because it looks like a sausage), pitting of a couple of finger nails and some psoriasis in the Umbilicus (belly button). The diagnosis then went from a localized/isolated tennis elbow to a diagnosis of Psoriatic arthritis.
Psoriatic arthritis comes in many forms and varieties. It can look just like rheumatoid arthritis (RA), involve the spine in a way similar to ankylosing spondylitis (inflammation of the spine), and can be associated with non-musculoskeletal issues such as sores in the mouth and inflammation in the eye. Of course, it is also possible to have Rheumatoid Arthritis in combination with, but unrelated to psoriasis. It is an excellent example of how the pattern of joint involvement can be a clue to the correct diagnosis, and of how the precise diagnosis can be elusive, but is usually more straight forward in the hands of an experienced physician who knows what questions to ask and takes the time to do a thorough exam. Psoriatic skin/nail changes, may predate the joint symptoms, or even follow the joint symptoms by years.
X-rays and labs can assist in the diagnosis, but can be as confusing to the “uninitiated/inexperienced” observer as they can be helpful. Psoriatic arthritis is, as are most illnesses, diagnosed primarily with a good history, good physical exam, and experience helps. The lab and x-rays are only ancillary. Just because a patient has a positive Rheumatoid factor, does not mean that they have RA and not psoriatic arthritis.
Patients have chronic illness, characterized by periods of relative improvement and then periods of flare-ups i.e., worsening. Our aim is to control the numbers of flares, the severity of the baseline level of inflammation, discomfort and disability, and to lessen the severity and the duration of flares. Ultimately, we aim to place the problem into prolonged remission
with drugs such as Methotrexate, and other DMARD (Disease Modifying Anti-rheumatic Drugs) and/or the Biologic modifiers, such as Remicade, Humira, Enbrel, just to mention a few. Because of potential side-effects, we tend to use less often, the class of drugs known as Non-steroidal anti-inflammatory drugs (NSAIDs). Since I had started in practice, the treatment has improved by leaps and bounds.
From time to time, we, at AARA PC might have a research protocol or two aimed at psoriatic arthritis, and it wouldn’t hurt to periodically call us and check up on this if one has been diagnosed as having Psoriatic Arthritis. We also have ongoing research studies for RA, and OA and other varieties of Rheumatic disease.
Cortisone (e.g. prednisone) and NSAIDs e.g. ibuprofen, naproxen can help symptoms but do not have the ability to modify the joint destruction and functional decline. They may cause stomach bleeding, poor kidney function, high blood pressure and cardiovascular side effects among other side effects.
Disease modifying anti-rheumatic drugs (DMARDs) have the capacity to drive the disease to a low activity state. The gold standard methotrexate at 15-25 mg per week, Arava, sulfasalazine, and the less potent Plaquenil are examples. But they often fail to induce remission. Newer biologic agents especially when used with methotrexate can affect good clinical outcomes. They include Enbrel, Remicade, Humira, Orencia, Rituxan, Cimzia, Simponi, and Actemra (listed in the order of approval by the FDA). However, even on these agents most RA patients do not achieve remission and they also may cause mild and serious side effect which limit their use. More research is needed to refine treatments with these agents and to identify new more effective, safe and less expensive drugs to help patients with RA. Only when RA patients volunteer for clinical research trials are better therapies discovered.
The physicians in practice at Arizona Arthritis & Rheumatology Associates and their research division Arizona Arthritis & Rheumatology Research are dedicated to the care of patients with RA. They helped develop the available RA therapies and are investigating new drugs on the horizon. We encourage patients with RA to contact us to participate in our growing research efforts and to become patients of our cutting edge rheumatology center.