From healthcentral.com
Newly diagnosed? Brief yourself on these PsA must-knows, and then bring this list of questions to your doctor
A diagnosis of chronic illness can leave you with more questions than answers and a complex disease like psoriatic arthritis (PsA) can be especially confusing. Psoriatic arthritis isn’t a condition people know much about, unless they have it or someone close to them does. If psoriatic arthritis has made an appearance in your life, you’re going to want to know what to ask your doctor. Read on to get a briefing on the major FAQs for this condition, and then bring this list, plus any other questions that pop up, to your rheumatologist appointment so that you can get answers.
What Caused My Psoriatic Arthritis?
Psoriatic arthritis is an autoimmune condition that causes the body to attack healthy cells in the joints, as if they were a bacteria or virus that needs to be fought. The exact cause of psoriatic arthritis is unknown, but experts think a combination of genetics (a family history and specific inherited genes) and environmental factors (stresses to the body like infection, injury, psychological stress, and obesity) ultimately come together to trigger the condition, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS).
“Autoimmune conditions tend to be more common in females, but PsA affects females and males equally in adults,” says Dori Abel, M.D., a paediatric rheumatologist in Philadelphia.
How Will You Diagnose My Condition?
Since no single test can diagnose the condition, your doctor will take several steps to determine if psoriatic arthritis is causing your symptoms. These steps can include:
Taking a Full Family History
You are more likely to have psoriatic arthritis if a family member has psoriasis or psoriatic arthritis.
Performing a Physical Exam
“The most important test is a clinical exam, as there are certain signs and symptoms which are very typical for psoriatic arthritis,” says Lisa Mandl, M.D., a rheumatologist at Hospital for Special Surgery in New York City. During this exam, your doctor will ask about what symptoms you’ve been experiencing and examine your joints (looking for swelling and tenderness), skin, and nails to look for changes consistent with PsA and psoriasis.
Doing Lab Work
You may also have blood drawn and tested. Some biomarkers found in the blood, like erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) signify inflammation, and that can tell your doctor that you likely have an autoimmune condition, per the Arthritis Foundation. However, they don’t automatically mean you have psoriatic arthritis. Other substances in the blood, like rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibodies, can rule out rheumatoid arthritis. Even if blood tests are negative, they can help determine what conditions you don’t have, Dr. Mandl notes.
Ordering Imaging Tests
X-rays, MRIs, and ultrasounds can find changes in the joints and surrounding tissues that signify psoriatic arthritis inflammation and damage.
Taking a Sample of Synovial Fluid
Synovial fluid is a lubricating liquid found in the joints that keeps bones from rubbing against each other and allows the joints to function smoothly. A synovial fluid analysis, which involves removing some of this fluid from a swollen joint and sending it to a lab to test for signs of inflammation, can also help rule out other conditions such as gout or an infection, says Dr. Mandl.
What Are the Most Common Symptoms of Psoriatic Arthritis?
Psoriatic arthritis symptoms and the order in which they show up, can vary from person to person. Most people with psoriatic arthritis have psoriasis first, but it’s also possible to have joint pain before experiencing any skin symptoms, per NIAMS. (It’s also possible to have PsA without psoriasis, Dr. Abel notes.) The most common symptoms of psoriatic arthritis include:
Joint Issues
Joint-related symptoms may include:
Stiffness, pain, and swelling of one or more joints that’s often worse in the morning or after periods of inactivity
Painful, sausage-like swelling of an entire finger or toe (dactylitis)
Tenderness in the areas where tendons or ligaments attach to bones, like the back of the heel and sole of the foot
The joints of the fingers—and specifically, the distal interphalangeal joints (DIPs), which are the last knuckles before your nail beds – are most often affected by psoriatic arthritis, says Dr. Abel. However, she adds, it can also affect other joints, including the knees, ankles, elbows, wrists, spine, neck, and hips. Psoriatic arthritis is often asymmetric (meaning it doesn’t necessarily impact matching joints on both sides of the body), but when it affects many joints (more than five), it is likely to become more symmetric, Dr. Abel says.
Other Symptoms
Non-joint-related symptoms of psoriatic arthritis can include:
Fatigue
Scaly, inflamed patches of skin, commonly on the scalp, elbows or knees
Nail changes, such as pitting (tiny dents), crumbling, or separation from the nail bed
Eye inflammation that causes pain, redness, and blurry vision
How Will You Treat My Condition?
"There are two types of initial treatment for psoriatic arthritis: treatment to improve your symptoms quickly so that you feel better, and treatments to stop psoriatic arthritis from getting worse over time and damaging your joints,” says Dr. Mandl. Factors like which body parts are affected, the severity of your symptoms, which ones bother you the most, other health problems you have, and your health insurance will all influence what treatment your doctor starts you on, per the Arthritis Foundation.
For example, “If someone only has a joint or two involved, we may just inject that joint with steroids,” Dr. Abel says. But when it’s more than a couple of joints, or if the arthritis keeps coming back in the same joint and you need repeat injections, “you want to be considering systemic therapy,” she says. Many people with psoriatic arthritis should expect to be on long-term therapy that keeps their disease under control and prevents progression and joint damage.
Treatments for psoriatic arthritis include:
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
NSAIDs like ibuprofen, naproxen, aspirin, and nabumetone treat mild psoriatic arthritis by reducing inflammation and improving joint pain.
Corticosteroids
Steroids—most commonly prednisone—are used to quickly reduce inflammation and get symptoms under control. They can be helpful during a flare or as a bridge until a new treatment starts to work, which can take a few months, Dr. Abel says. Steroids can be taken orally or via injection.
Disease-Modifying Anti-Rheumatic Drugs (DMARDs)
These drugs lower inflammation, reduce symptoms, and prevent joint damage by suppressing the body’s overactive immune system. Examples include:
Arava (leflunomide)
Azulfidine (sulfasalazine)
Rheumatrex (methotrexate)
Biologics
A biologic is a type of DMARD made from a living microorganism or cell. These medications target specific proteins in the immune system to control psoriatic arthritis; most are taken by injection or IV. They’re classified according to what part of the immune system they zero in on. A few examples:
Tumour necrosis factor (TNF) inhibitors. Remicade (infliximab), Enbrel (etanercept), Humira (adalimumab), Cimzia (certolizumab), Simponi (golimumab)
Interleukin-17 (IL-17) or interleukin 12 and 23 (IL-12/23) inhibitors. Cosentyx (secukinumab), Tremfya (guselkumab), Siliq (brodalumab), Stelara (ustekinumab)
T-cell inhibitors. Orencia (abatacept)
All medications come with potential side effects and psoriatic arthritis drugs are no exception. The side effects that you might experience depend on the type of medication you’re taking.
NSAIDs: Using NSAIDs long-term can cause stomach irritation and ulcers, internal bleeding, kidney problems, and heart problems.
Corticosteroids: Steroids are meant to be used only short term because they can cause some pretty rough side effects with long-term use, including osteoporosis, high blood pressure, adrenal insufficiency, diabetes, mood problems, and glaucoma.
DMARDS and biologics: DMARDs and biologics are the strongest and most effective medications for PsA. “They work to quiet the inflammation in joints and skin by lowering the immune system, which also puts you at a slightly increased risk of infection,” says Dr. Abel. Depending on the medication, side effects can include fever, mouth sores, hair loss, stomach upset, fatigue, and liver and kidney damage. When taking one of these medications, your doctor will send you for regular bloodwork to make sure you’re tolerating it well and that they catch any changes in the liver and kidneys early, Dr. Abel says.
A few lifestyle shifts can help improve psoriatic arthritis symptoms and overall health.
Exercise
“It is important to be active, especially if you have not been because your joints have been hurting,” Dr. Mandl says. Exercise has been shown to reduce pain and improve physical function in people with PsA, according to research on optimal lifestyle management of PsA in Rheumatic & Musculoskeletal Diseases Open. The reason is unclear, but it could be because exercise has anti-inflammatory effects, helps with weight management, and improves mobility and strength in the muscles and tissues that support the joints. Increased physical activity also helps prevent associated conditions such as heart attack, stroke, and diabetes, Dr. Mandl notes.
Weight Management
Maintaining a healthy weight is an important part of living better with psoriatic arthritis. “People with psoriatic arthritis can be at increased risk of weight gain as they get older,” Dr. Mandl notes. Excess weight not only increases the risk of comorbidities like heart disease, stroke, metabolic disease, and diabetes, but fat tissue also contains inflammatory cells, so reducing it can be beneficial, per the RMD Open research. People who are overweight may also not respond as well to psoriatic arthritis medications, per research on obesity and PsA in Rheumatology and Therapy.
“Eating a healthy diet, such as a Mediterranean diet high in omega fatty acids, is also a good idea,” says Dr. Mandl. There’s not one best diet for PsA, but focusing on good nutrition and a healthy diet can help with weight maintenance and reduce the risk of cardiovascular disease and metabolic disease—both of which people with psoriatic arthritis have a higher risk of developing, per the RMD Open review. Some research also suggests that eating more anti-inflammatory foods can help promote lower levels of inflammation in the body, though there’s not a lot of strong evidence, the review notes. “The best evidence is for the Mediterranean diet,” says Dr. Abel. “That means focusing on whole grains, legumes, fruits, vegetables, lean meats, and proteins.”
Sleep
Getting good quality sleep may also help with disease management. For one, sleep deprivation affects the hormones that control hunger and satiety, and makes you more likely to overeat and choose unhealthy foods, per the RMD Open review. It also increases cortisol and promotes inflammation.
Do I Still Need to See My Other Doctors?
Short answer: Yes! Your rheumatologist will be your point person for all things psoriatic arthritis, but your other doctors still play an important role in your overall healthcare. For example, you’ll want to see your usual providers for age-appropriate cancer checks, like a pap smear, mammogram, and colonoscopy, Dr. Mandl says.
“You should also see a dermatologist yearly for a skin check, as many of the medications used for psoriatic arthritis increase your risk of non-melanoma skin cancers, including basal cell and squamous cell carcinoma,” Dr. Mandl notes.
Is It Normal to Feel Tired?
Unfortunately, yes. Fatigue is common among people with psoriatic arthritis. One study on fatigue in psoriatic arthritis in the Annals of Rheumatic Diseases found that almost half of all study participants experienced at least moderate fatigue, with over 27% experiencing severe fatigue. Another study on fatigue in psoriasis and PsA in Advances in Dermatology and Allergology also found that 28% of participants with PsA reported severe fatigue compared to 17% of those with psoriasis and 1.6% of the control group with neither condition.
Psoriatic arthritis may cause fatigue directly—constantly fighting inflammation drains your body’s resources—and indirectly, as a result of medication side effects, inactivity, anaemia, depression, and lack of sleep (due to pain). Since fatigue seems to be partially caused by inflammation and pain, getting the disease under control with the proper treatment can help improve your energy levels.
Exercise is also beneficial for combatting fatigue, Dr. Mandl says. “You have to wait until your inflammation is under control, and there is often a lag time between getting the inflammation under control and fatigue getting better,” she notes. “Once you start exercising, ramp up slowly, and don’t be discouraged if you are more tired initially.” Once you adjust to the activity and make it a regular part of your routine, it can be energizing.
“Taking care of one’s mental health is also really important,” says Dr. Abel. “There’s a lot of work being done in rheumatology in general and in psoriatic arthritis specifically about mental health because there’s a lot of overlap between depressive symptoms, fatigue, and psoriatic arthritis,” she explains. “If you’re depressed and don't want to move, that’s going to stiffen the joints. You also get endorphins from exercising, so if you don't do it, you can get depressed, and it’s this vicious cycle.” Seeing a therapist and being treated—either with therapy, medication, or both—for depression symptoms can help with overall psoriatic arthritis symptoms, especially fatigue, Dr. Abel says.
Remember, psoriatic arthritis is a systemic disease, so shoring up your overall health, both physically and mentally, is a great way to improve the condition and help you feel better day-to-day.
https://www.healthcentral.com/condition/psoriatic-arthritis/questions-to-ask-your-doctor
