Defining Minimal Disease Activity in Psoriatic Arthritis with rheumatologist Dr. Arthur Mandelin Transcript
“Welcome to this episode of Psound Bytes™, a podcast series produced by the National Psoriasis Foundation, the nation’s leading organization for individuals living with psoriasis and psoriatic arthritis. In each episode someone who lives with psoriatic disease, a loved one or an expert will share insights with you on living well. If you like what you hear today, please subscribe to our podcast and join us every month at Psound Bytes™ for more insights on understanding, managing, and thriving with psoriasis and psoriatic arthritis.”
Jeff: Hi, my name is Jeff Brown and welcome to Psound Bytes™.
LB: And I’m LB Herbert, you may recognize us from our episodes earlier this year about living with psoriasis and psoriatic arthritis, episodes 243 and 244. Today, we're here to discuss what is minimal disease activity, also called MDA, in relation to psoriatic arthritis – specifically, how to get there and why it's important. I know I'm curious to learn more about what MDA is in psoriatic arthritis. How about you, Jeff?
Jeff: I am. To help us learn more about minimal disease activity in psoriatic arthritis is rheumatologist Dr. Arthur Mandelin, an Associate Professor of Medicine at Northwestern University Feinberg School of Medicine and the Department of Medicine, Division of Rheumatology, where his clinical interests include psoriatic arthritis, rheumatoid arthritis, gout, ankylosing spondylitis, joint injections and interventional ultrasound.
LB: It's exciting to meet you Dr. Mandelin. I've heard you also launched Northwestern University's first ever training program in musculoskeletal ultrasonography for rheumatology fellows. You are also an active participant in the REASON Group. A multi-center research collaboration devoted to using ultrasound guidance to obtain minimally invasive synovial tissue biopsies. That's exciting to hear.
Jeff: And LB, Dr. Mandolin is also a past member of the National Psoriasis Foundation’s Medical Board and a professional member of the Foundation. As a member of the Medical Board, he served on the consensus panel for the development of a variety of practice guidelines. Last year, he received the Provider of the Year award from the National Psoriasis Foundation for the Chicago area.
LB: Thank you, Dr. Mandelin, for taking time to be here today. We really appreciate all that you do for NPF, and it's a pleasure having you back on Psound Bytes.
Jeff: Dr. Mandelin, when you were last on the show in 2019, you addressed psoriatic arthritis versus rheumatoid arthritis and osteoarthritis and gout in episode 21. There's been a movement to identify a minimal disease activity. Can you speak to why this movement has occurred and what is minimal disease activity or MDA in relation to psoriatic arthritis?
Dr. Mandelin: Yeah. So the reason why there's been a movement toward identifying minimal disease activity is that we have good data now from a number of different studies that demonstrate that patients whose psoriatic disease and particularly psoriatic arthritis is under better control will have better outcomes. And indeed the guidelines state that we should try to achieve remission for all those patients for whom remission is achievable. To be honest, that's not a large number of patients, but we should always be striving for that in those patients where we can get there. And for those patients who can't get to remission, we should have them in the lowest disease activity we can reasonably achieve. So there are various different ways to measure what is psoriatic arthritis disease activity and there are various ways to measure what is low or minimal or different groups have different terms for this. We're gonna use today MDA, minimal disease activity. The idea is that a patient who has psoriatic arthritis who is in minimal disease activity statistically speaking has a better chance of having a good long term outcome than someone who is in some higher disease activity state other than minimal disease activity. So that's the importance of being in minimal disease activity or MDA. And in terms of what minimal disease activity is, there again there are various different definitions from various different groups, but the one we're talking about today, MDA, there are seven different criteria or seven different things about the patient that we look at and we want the patient to meet five out of the seven criteria for immunol disease activity.
LB: Thank you. That was a great definition. How does MDA compare to response criteria ACR20 or ACR50, which are typically heard in reference in psoriatic arthritis clinical trials?
Dr. Mandelin: I think the key there is those last two words, clinical trials. So ACR20 and ACR50 are used when we do research on psoriatic arthritis and there are a few things that are important about those criteria. Probably the first and most important is that generally speaking when a new therapy is invented and the manufacturer goes to the FDA and says, “Dear FDA, may I please sell my drug in the United States for the treatment of psoriatic arthritis?” The FDA is going to want to know is that drug safe and is that drug effective? The safety part is answered by looking at clinical trials and seeing what types of adverse events do or do not happen to patients who are on the drug and the effectiveness of the drug is done by the ACR20, ACR50. And we often also speak of ACR 70 response criteria. And very broadly, just very quickly since that's not the focus of ours discussion today, the ACR 20/50/70 response criteria basically say that when the patient is on therapy, their disease becomes 20% better or 50% better or 70% better. ACR 20, 50 or 70 than it was before they started that therapy. Generally speaking, we consider ACR 20 to be roughly the point at which we can confidently say that this therapy is better than placebo (better than nothing) and that tends to be the absolute minimum threshold we need to cross in order for the FDA to say this medication or this therapy is useful enough that it makes sense to proceed forward with it. Now obviously we would want people to have more than just an ACR 20 better than placebo response. But that is the absolute minimum bar that a drug needs to pass in the United States in order to be considered worthy of approval by the FDA. Some other important things about that is that the ACR 20, 50 and 70, because we're talking about a percent response on therapy versus a percent response prior to therapy, by definition, we need two time points. You can't look at the patient today and without looking back in time or forward in time and tell whether or not they are an ACR 20, 50 or 70 responder. You need two time points to compare an on therapy versus a prior to therapy, an on therapy versus an off therapy. The MDA disease activity, the minimal disease activity criteria that we are talking about today can be done in the context of a single visit. You can walk in and examine the patient one time, during one single office visit, and know that they are or are not in MDA by those criteria.
Jeff: Dr. Mandelin, you mentioned achieving minimal disease activity means meeting five out of seven criteria. Can you explain what exactly that criteria is for reaching MDA?
Dr. Mandelin: So those seven criteria are the number of tender joints on physical examination. The number of swollen joints on physical examination. The Psoriasis Area and Severity Index score, also called the PASI score. The patient's assessment of how well they are doing overall, not just in pain but in terms of all the ways in which their disease impacts their life. The amount of pain that the patient does experience and then the number of entheseal points which are tender in that patient. And an entheses is an area where a tendon approaches and connects to and lands on a bone. The most obvious entheses that we all think about and the one that's often most involved in our inflammatory forms of arthritis is the so-called Achilles Heel where the tendon attaches to the calcaneus at the posterior aspect. So a patient who is having less than or equal to one tender joint less than or equal to one swollen joint, whose skin Psoriasis Activity Severity index is one or less, who rates their global impact of their disease as 20 out of 100 or two out of 10 or less. Who rates their pain as 15 out of 100 or 1.5 out of 10 or less, and who has no more than one tender entheseal point can be said to be in minimal disease activity.
LB: Dr Mandelin, I’m curious, in your years of managing patients with psoriatic arthritis are there any indicators that have led you to realize that a patient can achieve MDA whereas another patient will struggle to reach minimal disease activity?
Dr. Mandelin: In my personal experience, it's been really difficult to determine ahead of time who can and who cannot achieve MDA. There has been research that's been published that has suggested that patients who have so-called axial involvement, where their spine is part of the problem or part of the involved organ systems with their psoriatic disease, may have a harder time getting to minimum disease activity or MDA. That being said, I've been surprised in both directions. There have been patients who come in looking very strongly involved who do extremely well on therapy, and there have been patients who come in who aren't maybe completely miserable, but they obviously have an issue that they need help with, who no matter what we do, they tend to just continue to simmer on and simmer on, and their disease activity never seems to budge very much, or at least not to the degree that they need. So that's one of the frustrating things about all inflammatory forms of arthritis, including psoriatic arthritis, is that we don't really have a good way to predict in advance who's going to respond well and who's not going to respond well. And I think one of the things that we're going to get into later in the discussion is that we also don't have a good way to determine who's going to respond to what drug. But we'll get to that later I think in the talk.
LB: And why is axial disease for psoriatic arthritis a negative factor for MDA?
Dr. Mandelin: Short answer to that is we wish we knew. There's been this observation that patients who have axial disease are less likely to achieve minimal disease activity (MDA) than patients who do not have axial or spinal disease. But we don't really understand the why. This is an observation. We know that it happens, but the why is something that remains elusive.
Jeff: Dr. Mandelin, why is it so important to achieve MDA? And is there a point in the disease process when it's important to do so and what's the outcome if you can't reach minimal disease activity in that specific time frame? In general, I've been in a pretty good state of remission over the last couple years. But there have been times when I've fallen out of it and I'm just really grateful that we've got so many great treatments out there. I had some knee injections the last few weeks and it's made a big difference. So while my overall treatment has been going well, it is nice we have so many options out there to supplement that when you kind of fall off the remission bandwagon.
Dr. Mandelin: It's important to achieve the minimal disease activity for the reasons we've already discussed. Patients who can get to MDA, statistically speaking, have a better chance of a better outcome in the long run. We would prefer to get to MDA as quickly as we can, reasonably speaking because patients who are not in MDA are at risk not only of just not feeling well, but some of the other things that we think about with psoriatic disease and psoriatic arthritis, things like in some cases bone damage, bone erosion. If we don't have the disease under good control, patients are more likely to experience those additional negative effects from their disease. Now granted, even a patient who's under good control can still theoretically get problems like bone damage, but the general idea is that if we can keep the fire turned down as low as possible, we're going to get as minimum number of burns so to speak as we can. So we need to keep the disease activity low and we need to get that disease activity low as quickly as we reasonably can because letting it simmer, letting it boil is letting damage occur in some patients. So that's the important reason why we want to get to MDA as early as we can reasonably speaking. The reason I keep saying reasonably speaking is a lot of our medications don't work quickly. So on the one hand, we do want to get to MDA as soon as we can, but on the other hand, that doesn't mean that we want to just say that's not working, new drug. That's not working, new drug. That's not working, new drug. We need to give each drug the appropriate amount of time and just recognize that a lot of our medications don't work very quickly. Far from working overnight. Some of the quick obvious examples there would be steroids. Steroids can work very quickly, but that's not something that you can be on long term, especially at higher doses. The types of medications that we think about for chronic control of disease by and large, just by the way that they work in the body are going to be slow. The patient is going to need, in many cases, three months, 12 weeks before we can definitively say this is as much as we're going to get from this medication. And at that point, we can step back and say, is this enough or do we need to make a change? And it's frustrating for us and for the patients because every time we do this, every time we switch to a new drug, it's generally speaking another 12 weeks that we have to just give the drug time. So we do what we can, but we do need to move deliberately and give each drug an appropriate amount of time to do its work and not leave a drug prematurely. And then in terms of what if we can't reach minimal disease activity, then we just strive for the lowest achievable disease activity that we can get to whether that be minimal or whether that be just some other lower level of disease activity. As much control as we can muster.
Jeff: So, given the importance of achieving minimal disease activity, what actions can patients take to make sure diagnosis occurs early in the disease process? When I was first diagnosed with psoriasis, I really didn't understand it could lead to psoriatic arthritis or I wasn't really watching out for any joint pain. If my doctor had mentioned that I probably would have, or if I'd just been vigilant and researched what I had, I would have been armed with the questions to ask and the symptoms to watch out for.
Dr. Mandelin: One of the most important things early in the disease process that a patient can do is to be first of all aware that psoriatic skin disease can evolve into psoriatic arthritis or other forms of psoriatic disease anytime during the first, in the case of psoriatic arthritis, we say perhaps 7 to 10 years after the onset of skin disease. For the majority of patients who are going to develop psoriatic arthritis specifically, they will begin as psoriatic skin disease. About 90% of psoriatic arthritis patients begin as psoriatic skin disease, apparently in isolation, and it can take them seven to 10 years to, for lack of a better word, evolve from skin only psoriatic disease into psoriatic arthritis, psoriatic disease. So first, the patient needs to be aware that this can happen. It only happens to about one patient in three, but it can happen. So they need to be aware that if they are a person who is still relatively early in their journey with their psoriatic skin disease, they need to be aware that when or if they develop musculoskeletal symptoms, bone and joint pain, swelling in the joints, that probably in their case is not a separate, unrelated situation. This could very well represent their psoriatic skin disease evolving into psoriatic arthritis. So they need to recognize that this can happen to them. And then if that starts to happen, they need to get in contact with their dermatologist, their primary care, somebody who is helping them with their health care to get them to the right type of person. I would, of course, in my bias I would suggest a rheumatologist who can then evaluate them to see do they in fact have psoriatic arthritis so that we can get them that early diagnosis, which is so important, which gets us a head start down the road to treatment and that hopefully gets us to minimum disease activity as quickly as we can reasonably get there.
LB: Generally, how long do you see patients achieve MDA or minimal disease activity? Is it months or potentially years before you need to revisit treatment options?
Dr. Mandelin: This is one of the things that's very, very different from patient to patient. As we mentioned earlier, most of our medicines that are the most effective ones, the ones that we can safely do in the long term are on the other side of that coin, not rapid and you need in many cases three months, 12 weeks of a trial of each medication before you can change to the next medication. So it really is a matter of, for lack of a better word, luck. Right, that patient who you just happened to stumble across the correct medication right away, they might get to MDA in three months or less. For that patient who needs to try two medications before they get to MDA, that by definition could be six months. If a patient needs three medications to get there, that could be nine months. Every time you try a new medication, you're basically tacking potentially another three months onto the time it takes the patient to get to MDA. So in some patients it will be only in the matter of months. And in some patients it can indeed be years before they get to minimum disease activity.
Jeff: Thanks for that information, Dr. Mandelin. How does MDA impact selection of treatment options? What do you reach for first pending how severe the PSA is? For example, my psoriatic arthritis really started in my knees and my shoulder, but I also had some strange things going with my fingernails which I really couldn't figure out why they looked the way they did until I went to my dermatologist who diagnosed me.
Dr. Mandelin: That unfortunately is one of the things that we also aren't very able to determine in advance. There is no way that we have that tells us which drug is best for which patient. Certainly because we want to get to minimum disease activity and because we want to get there as rapidly as we reasonably can, we want to go to more effective medications sooner. We don't want to spend a lot of time with medications that are not known to be highly effective for this disease process. We certainly don't want to take our psoriatic skin patient who has now developed psoriatic arthritis and keep treating them with only topical treatments and only non-steroidals like, for example, ibuprofen for pain control. We need to get them onto effective medication as soon as we can. But the magical question there is what medication for each patient is gonna be that magical medication and we really don't know. The best guideline we have so far is that psoriatic disease does get broken into six domains, and those domains of psoriatic disease can sometimes help to guide us in terms of maybe not which exact drug but which family or which class of medication we might want to lean toward, versus we might not want to lean toward. And in case you're curious, those key domains are peripheral joint disease, which is the opposite of axial. This is bone and joint disease outside the spine and hips. Versus axial joint disease, that's the second domain. Arthritis that is in the spine or in this case, we count the hips as being part of the spine for axial joint disease. We talked earlier about enthesitis, the area where a tendon connects to a bone. So if that's the thing that's driving the problem, we would need to be focused on that. Some patients will have swelling not just of a particular joint, but of an entire digit, a whole finger or a whole toe. That's called dactylitis. Of course patients who have psoriatic arthritis and can have skin disease as their predominant feature, even if they do still have some bone and joint issue, they could still have skin as the thing that's driving their personal experience, their journey through psoriatic disease. And then the sixth is nail disease. Some patients will have their fingernails and toenails as the driving thing that bothers them the most about their disease. So among those six domains non-spine bone and joint, spine bone and joint, tendon (enthesitis), whole digit dactylitis, skin, and nails. Sometimes if we determine which of those six areas is the one that bothers the patient most, or seems to be impacting the patient most, that may give us some clues. But it's not truly personalized medicine.
LB: Dr. Mandelin, while I realize treatment options are individualized, in general what do you feel are the best treatments for psoriatic arthritis?
Dr. Mandelin: The best treatments for psoriatic arthritis really are the ones that are given by prescription I guess I would have to say. Certainly there are patients who have very mild disease who may get some significant amount of relief from over-the-counter topical skin preparations, who may get good relief from over-the-counter Motrin, Naproxen, Aleve, ibuprofen. Those types of non-prescription pain medications, even Tylenol (acetaminophen) can be helpful for a number of patients. But we want to always be sure that we're really having that discussion with the patient, that we're seeing the patient in the office and doing an examination to determine if that patient, who in their perception is doing well on these non-prescription treatments really is meeting the criteria we've been talking about today for minimal disease activity, MDA. Some patients are able to tolerate quite a bit of discomfort and what they might perceive as being tolerable symptoms might not meet the MDA criteria, which, as we've been saying all morning, are kind of important here. So I think the best treatments really are ones that are selected in concert with ideally both a dermatologist and a rheumatologist who are observing the disease, looking at the level of activity, figuring out which of the six key domains are the one or ones that are most involved, and then helping the patient make a choice based on the clues that we can get from those aspects of their disease.
LB: And how do you treat the fatigue and pain associated with psoriatic arthritis? I know for myself that that's how I'm impacted the most and I have to pull in additional therapies to manage those symptoms.
Dr. Mandelin: That often is something that can really disturb patients, can really be the thing that becomes the driving factor that impacts their life in terms of their psoriatic disease. Oftentimes, frustratingly, when patients get to MDA, minimal disease activity and they meet all these criteria that we talked about earlier, you'll notice that other than pain, right, which we said 15 out of 100 or 1.5 out of 10 or less. But fatigue wasn't on that list, so theoretically you could get to MDA (minimal disease activity) and still be fatigued. Because minimal disease activity criteria don't look at fatigue and the problem we have with fatigue is it's another thing that it's very difficult to measure. You can't really put a number on fatigue in terms of a lab test or any type of an image that you can do of the patient's body. You have to rely on the patient's report, which I'm sure is accurate, but it it's not the same as getting a lab test that looks for fatigueness so to speak. And we don't really understand fully what the fatigue is coming from. The best theory we have right now is that some of the inflammatory process that's going on in psoriatic disease must be impacting the body and causing this sensation that we describe as fatigue. Even those of us who maybe don't have psoriatic disease, psoriatic arthritis, have all had the experience of having an inflammatory process like for example the flu. And when your body is all fired up with these inflammatory messages flying around the system trying to make you better, trying to help you fight the flu, we all recognize that the flu can make you feel really tired and run down and fatigued even though you've been lying in bed all day. And we think that's from these pro-inflammatory messages in the body having this effect on your system. So we believe as much as we can tell that that's probably where the fatigue of psoriatic disease is coming from, is that even when the disease is under decent control, there may still be some of these pro-inflammatory messages present in the body that are causing the fatigue issue. Unfortunately, we don't really have a specific treatment for fatigue. Often times, patients will come in and they will ask do you have a magic pill or something for particularly fatigue and the short answer to the question is no. We don't have anything that specifically treats fatigue in any of our inflammatory forms of arthritis, including psoriatic arthritis. The best thing that we can do for the moment is to try to get that inflammatory burden in the body down as low as we can get it. So this actually becomes potentially another reason to get that patient to MDA (minimal disease activity) because that might improve their fatigue to get that inflammatory fire, so to speak, to simmer down as low as we can reasonably get it in that patient.
Jeff: Dr Mandelin, what do you see as in the future for use of minimal disease activity in psoriatic arthritis?
Dr. Mandelin: I think as we continue to develop more and more effective therapies for psoriatic arthritis we might start getting to a point where we start to look at MDA as a treatment goal even more so than we do now. We may be getting to a point, for example we talked earlier about the ACR 20, 50, 70 response criteria that are used in research, right. Is this patient 20% better? If so, we call someone an ACR20 responder. Is this patient 50% better on their therapy? If so, we call them an ACR50 responder. A patient who gets 70% better when they're on treatment is called an ACR70 responder. That's where the scale stops. But the good news, perhaps the bright future we may be looking at down the road is there's been talk now with the therapies that are available that we might need to develop, recognize, and start looking for ACR 90. Your patient who gets 90% better on therapy in terms of a reasonable research goal that we should be looking at or at least categorizing. We should be breaking patients instead of into three groups, ACR 20, 50, 70, we should be saying how many of these patients reach ACR 90. The reason ACR 90 historically was not used was that our treatments just weren't that good. So few patients would get to ACR 90 that it didn't make any sense to even count them because the number would be so low. But now we're getting to that point where maybe ACR 90 becomes something we should be tracking. So in that same way that we might be in the future tracking ACR 90’s for highly effective therapies in the research context. Maybe we need to be looking at MDA (minimal disease activity) even more often, and even more strongly than we do currently, and we could even go one step further and say, should we really be starting to look at how many patients can we drive into remission with our current highly effective therapies, which was quite rare not that many years ago.
LB: That does sound promising. Before we end our discussion today, are there any new advancements in psoriatic arthritis we should know about? Jeff and I would really appreciate hearing the latest news out there.
Dr. Mandelin: So obviously I'm gonna take the opportunity and be a little bit self-serving here. There is a research program that's in process now. It's at several sites nationwide and it's the Accelerating Medicines Partnership Consortium also called “AMP” (Accelerating Medicines Partnership). And it's a collaboration between academic institutions and some of the industry partners. We are trying to answer this same question that I keep coming back to over and over during our discussion today about we don't know how to choose what specific drug for what patient or to be honest with you, we don't have great data for choosing what class, what type of drug, what family? When I talk to patients I say what family of drug should we be using in this patient versus that patient? We just don't know and we're really doing it by trial and error. As terrible as that sounds, it's the truth. We're treating these inflammatory forms of arthritis, including psoriatic arthritis, by trial and error, and we're hoping that we can find some sort of a marker in the body that would give us a hint ahead of time and help us say, well, we're going to skip this class of medication or that family of drugs and we're going to skip over the standard order and do that drug instead in this particular patient because we've discovered something about them that would tell us that drug C might be the one that's more likely to work and therefore it might be reasonable and justifiable for us to skip drugs A and B and go straight to C in that patient. Now, we've been looking for that for decades and haven't found it so far. And the thought is, at least in our group, the AMP group, is that there may be a problem where this magical marker that we're looking for that would tell us psoriatic disease that responds to drug A versus psoriatic disease that's going to respond to drug C, the reason it hasn't been found so far we think is that it isn't in the blood, which is where all the research or the majority of the research has been focused. So the thought behind AMP and specifically for psoriatic disease, the sub study or the study in process now is called AMP ellipsis. What we're doing is using ultrasound guidance and novocaine for anesthesia. We are actually sampling the inflamed joint capsule, the joint lining in psoriatic disease, and this has been done in some other disease states as well. And we're getting a sample of the actual inflamed tissue itself out of the patient, (volunteer patients who participate in this research). And we're subjecting that tissue to analysis to see if we can figure out some sort of a biomarker, some sort of a signal in that tissue that would tell us this particular patient’s psoriatic arthritis is going to respond to this family of drugs but not that family of drugs. We're not there yet and we don't currently have the ability to do this type of synovial biopsy under ultrasound guidance in a clinical context in the regular office. This right now is strictly a research based situation where the patient would need to apply to and be accepted into a research study to get that biopsy done. And I should also emphasize that because this is done in the context of research right now, even if we were to find something in one particular patient, it would be difficult, if not impossible, under the research protocols and regulations to go back to that patient and alter their therapy based on a biopsy that's still in an investigational situation. So we're hoping that the day will come when patients will come to us with psoriatic disease and particularly psoriatic arthritis, and during those first one or two office meetings with the patient, we can perform one of these biopsies, and based on that tissue select the correct drug. But we're not there yet. Right now it's still being done only as research. And these patients who are being so gracious and letting us do this procedure and harvest their tissue for analysis are basically doing it as a hope for the future rather than as anything that would guide their therapy today. But that's what we're thinking. That's right now what at least in my corner of the world and in the research that I'm doing updates in terms of where we're going with advancements for the future, and we’re hopeful that we're gonna get there.
Jeff: That's fascinating. That would really help patients get relief faster and not waste time and money on treatments that don't work for them. So that's very interesting. Thank you Dr Mandelin for the update. Do you have any final comments for our listeners?
Dr. Mandelin: I think the main thing that I would wanna leave the listeners with would be the idea that as we kind of said earlier patients who have skin disease only in terms of psoriasis should be vigilant. They don't need to be frightened. They don't need to have lifelong anxiety. But they need to recognize that they have roughly a one in three chance of developing psoriatic arthritis. And they just need to recognize that if bone and joint pain and particularly joint swelling or swelling of an entheses, as we said most commonly the Achilles heel, just seems to come out of nowhere. That this might not be something new and different and separate that this might be part of their psoriatic disease that they need to actually approach their dermatologist or their primary care, or if they have one, a rheumatologist. It sounds kind of weird. “I've got a swollen, painful heel or I've got swollen knuckles, so I'm gonna go see my skin doctor about my swollen knuckles?” But this is actually what you should do, because it might be part of your skin disease. The patient might be wondering then, why would they want to go and see their dermatologist if their skin disease seems to be all right, but they're developing new bone and joint pain with swelling. And the answer to that question is that in cooperation, the National Psoriasis Foundation has brought rheumatologists and dermatologists together, and there's been a push lately where we have recommended a number of very simple screening tools. Most of these are one page questionnaires that your dermatologist can go over with you to help you determine whether you're at risk for having your psoriatic skin disease evolve into psoriatic arthritis. One of these one page questionnaires is called the PEST, P-E-S-T, the acronym stands for Psoriasis Epidemiology Screening Tool and it's a simple one page questionnaire that you can go through with your dermatologist or any healthcare professional to determine if you score highly enough that you should be referred to a rheumatologist. So the most important thing is to be vigilant for the development of psoriatic arthritis. And don't let these things slide because the earlier we get to you the better chance we have of being able to do something that might be effective and the less time we're gonna waste.
LB: Minimal disease activity is a topic we may not hear our doctors talk about, but they're employing in practice. So to have this understanding is really valuable for future conversations. I can't thank you enough for taking the time to share this with us today.
Dr. Mandelin: Yeah. Thanks for having me. Its been a great talk.
Jeff: Yeah, as a patient myself, having so many treatment options available just gives me such optimism for the future, both for myself and our fellow listeners. Your message of prevention and keeping psoriatic arthritis in control is so important to share. And for our audience, May is Psoriatic Arthritis Action Month. If you would like more information about managing psoriasis or need help findig a rheumatologist, contact our patient navigation center at education@psoriasis org.
LB: If you found this episode helpful, please share the episode link with someone you know who may be experiencing symptoms of psoriatic arthritis or is at risk for developing the disease. Join us again for our next episode where you'll hear a discussion about psoriasis and osteoporosis with rheumatologist Dr. Diana Sandler.
Jeff: And lastly, thank you for listening to Psound Bytes™.
We hope you enjoyed this episode of Psound Bytes™ for people with psoriasis and psoriatic arthritis. If you or someone you love has ever struggled with psoriatic disease, our hope is that through this series you’ll gain information to help you lead a healthier life and inspire you to look to the future. Please join us for another inspiring podcast. You can find this or all future episodes of Psound Bytes™ on Apple Podcasts, Spotify, iHeart Radio, Gaana, and the National Psoriasis Foundation web page. To learn more about this topic or others please visit psoriasis.org or contact us with your questions or comments by email at podcast@psoriasis.org.
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