To treat or not to treat? Managing PsA flares

| Melissa Leavitt

Psoriatic arthritis flares are tough to pin down. Some patients may zero in on a certain joint, while others describe an overall achy feeling. Skin flares are sometimes part of the picture, while at other times, it feels more like a case of the flu.

But identifying flares is only half the battle. For doctors, the variation of symptoms from patient to patient makes effectively treating psoriatic arthritis flares a challenge.

Dr. Alexis Ogdie, a rheumatologist at the University of Pennsylvania and director of the Penn Medicine Psoriatic Arthritis and the Spondyloarthropathies Program, tackled the topic of psoriatic arthritis flares in a National Psoriasis Foundation webinar for medical providers on May 25.

Sharing insights from research in the field and her own clinical experience, she offered pointers on working with patients on self-care strategies and knowing when it’s time to try more aggressive treatment.

Here are five tips from Ogdie on managing psoriatic arthritis flares. 

1. Don’t just focus on the joints.

Citing a 2015 study by lead author Anna Moverly published in the journal Rheumatology, Ogdie urged providers to remember that “a flare of psoriatic arthritis is not limited to the joints.”

Flares aren’t limited to physical symptoms either, Ogdie said.

Pain, heat, stiffness and swelling in the joints can be part of the flare experience, as can worsening skin psoriasis. Other symptoms, such as feeling more tired than usual or not being able to participate in daily activities, can be tougher to recognize.

“Fatigue is clearly a very severe and important symptom that accompanies flare,” she said.

All of these symptoms can occur separately or in combination, according to Ogdie.

“The patient may be flaring in terms of just the skin, or the patient may be flaring in terms of the arthritis, or both,” she said.

2. Make sure it really is psoriatic arthritis.

“Once we assess the patient, the first thing to consider is, ‘Is this person’s increase in joint pain really related to the psoriatic arthritis? Or is it something different?’” Ogdie said.

Other possible explanations Ogdie offered for patients’ symptoms include gout, septic arthritis, fibromyalgia or a musculoskeletal issue.

3. Understand flare triggers.

There is not a lot of data available on what can trigger a psoriatic arthritis flare, Ogdie said. But patients note a number of possible triggers, including stress, changing medication, over-exertion and poor diet.

Lifestyle modifications can be one way to address flares triggered by these factors. For instance, healthy eating, exercise, getting enough sleep and consistently taking their medication can be useful strategies that patients can do on their own to address flares.

“Self-management may include taking a day off work to rest and catch up on sleep, or being diligent about getting a good night’s sleep on a regular basis,” Ogdie said.

4. Recognize when it’s time to turn up the treatment.

Ogdie discussed three types of flares. Flares characterized by an increase in symptoms within a normal variation and short-lived flares caused by an external trigger may be most amenable to self-management, she said.

But the third type, which involves an unprovoked and persistent increase in disease symptoms, may call for more than self-management.

The 2015 GRAPPA Treatment Recommendations and the 2015 EULAR Treatment Recommendations can guide clinicians’ decisions regarding treatment, Ogdie said.

Before making a medication change, doctors should consider all of the disease manifestations a patient may be experiencing, according to Ogdie.

“You want to pick a therapy that’s going to cover as many of their disease manifestations as possible,” she said. These might include axial disease, peripheral disease, enthesitis, dactylitis or other domains.

Clinicians should also consider how often flares are occurring.

Citing a 2015 study of rheumatoid arthritis flares by lead author Dr. Iris Markusse in the journal Arthritis Research and Therapy, Ogdie said that patients who experience more flares over time could be at risk for poorer clinical outcomes.

“A flare every once in a while is not that big of a deal,” Ogdie remarked. “Multiple flares may suggest worse long-term outcomes.”

“That’s probably someone who may need more aggressive therapy,” she said.

5. Don’t delay follow-up.

After patients and providers settle on a management strategy, it’s important for doctors to check back in with their patients soon by phone or through a follow-up visit.

Four to six weeks is a good time for a follow-up check in, Ogdie advised.

Dr. Ogdie’s webinar is available on-demand here.

The National Psoriasis Foundation offers a range of in-person and online continuing education opportunities for medical professionals. For more information, click here

Driving discovery, creating community

For more than 50 years, we’ve been driving efforts to cure psoriatic disease and improve the lives of those affected. But there’s still plenty to do! Learn how you can help our advocacy team shape the laws and policies that affect people with psoriasis and psoriatic arthritis – in your state and across the country. Help us raise funds to support research by joining Team NPF, where you can walk, run, cycle, play bingo or create your own fundraising event. If you or someone you love needs free, personalized support for living a healthier life with psoriatic disease, contact our Patient Navigation Center. And keep the National Psoriasis Foundation going strong by making a donation today. Together, we will find a cure.

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