SIMEDHealth

Psoriatic Arthritis Advances

 

Dr. Tina Brar of SIMEDHealth's Arthritis Center recently wrote an article for House Calls Magazine, a seasonal publication for the Alachua County Medical Society. The following article discusses advances in the treatment of psoriatic arthritis. 

View the full article below:

To request an appointment with Dr. Brar, click here

 

Article content:

 

Introduction
Although  psoriasis  has  been  described  since  the  time of   Hippocrates,   psoriatic   
arthritis   was   identified   as   a separate disease entity in the 1960s by what is now the 
American College of Rheumatology (ACR).  Initially thought to  be  benign,  it  is  now  recognized 
 as  a  member  of  the spondyloarthropathies  and  is  a  debilitating,  progressive illness with 
a comparable impact on functional ability and quality of life as rheumatoid arthritis (RA).  Early 
diagnosis is  imperative  to  prevent  long-term  disability  and  ensure optimal management of the 
disease and its comorbidities.

Psoriatic   arthritis   (PsA)   is   a   complex   affliction   with musculoskeletal involvement- 
including arthritis, dactylitis, enthesitis and/or axial involvement as well as skin and nail 
disease.   Although the exact pathogenesis is not known, it is thought that genetic, immunologic 
and environmental factors play a role.   The prevalence of PsA in the United States  is  around  
0.25%,  however  about  30%  of  patients with psoriasis also have psoriatic arthritis, affecting 
men and women equally.   It is therefore prudent to screen all psoriasis patients for PsA.  Varying 
patterns of the disease mimic different inflammatory conditions, such as gout and RA.  
Approximately 15% of patients develop arthritis prior to skin involvement, making the diagnosis 
difficult.  Generally, laboratory tests are unhelpful as there is no specific test for PsA and 
systemic inflammatory markers may be elevated in only half the cases.  The genetic marker HLA-B27 
is not a diagnostic test as no more than 2% of people born with this  gene  will  eventually  
develop  a  spondyloarthropathy. A    multidisciplinary    approach    between    dermatology and  
rheumatology  is  helpful  in  analyzing  many  cases. Recognition of this disease process has 
increased with the introduction of the classification criteria, CASPAR, as well as the development 
of several screening tools that allow for timely intervention.

Treatment

Anecdotally,  treatment  options  for  PsA  were  limited  to non-steroidal    anti-inflammatory    
drugs    (NSAIDs)    and conventional    disease-modifying    anti-rheumatic    drugs (DMARDs).  
Initially developed to treat rheumatoid arthritis, these   medications   have   varying   benefits  
 in   treating inflammation and the vast manifestations of PsA as well. Multiple systematic reviews 
have determined that the effect size of these DMARDs such as methotrexate, sulfasalazine and 
leflunomide are not very high and cyclosporine is seen as  toxic.   Corticosteroids  can  be  used  both 

locally  as injections and systemically, although not supported by evidence-along  with  the  concern

  of  rebound  psoriasis upon withdrawal of the drug.

Spanning  the  past  decade,  the  availability  of  targeted synthetic   and   biologic   DMARDs   
has   revolutionized treatment.    Given  these  advances,  a  “treat-to-target” approach  towards  
management  has  been  proposed, following  its  favorable  application  in  other  rheumatic 
conditions.     The  ultimate  objective  of  therapy  is  to procure the lowest possible level of 
disease activity in all aspects of the illness.  Despite a lack of cure, there are now effective 
treatments.

Tumor necrosis factor inhibitors (TNFi), which block the inflammatory  mediator  TNF-α,  have  been 
 around  for over  two  decades  and  have  established  breakthrough efficacy in patients with 
PsA. Five TNFi are now available, including adalimumab, etanercept, infliximab, golimumab and  
certolizumab.   Along  with  improvement  in  clinical signs  and  symptoms,  these  treatments  
also  decrease radiographic evolvement of disease.  All TNF-α blockers have been studied in 
randomized control trials as well as  in  observational  studies  with  consistent  evidence 
supporting  their  efficacy  and  safety  in  PsA.   Currently, trial  data  is  limited  in  
regards  to  switching  from  one inhibitor to another, although clinically it is a successful 
strategy.    The  choice  of  agent  is  based  upon  patient preference as well as regulatory and 
payor requirements and/or limitations

In  recent  years,  new  biologics  with  alternative  modes of  action  have  also  been  tested  
and  approved  in  PsA. Ustekinumab  is  an  FDA  approved  IL  12/23  inhibitor with  evidence  in 
 treating  arthritis,  skin,  enthesitis  and dactylitis. Guselkumab, an IL-23 blocker, is 
currently FDA approved for psoriasis only and is under investigation for the management of PsA with 
promising data.

Research  now  highlights  the  importance  of  the  TL- 17  pathway  and  a  number  of  therapies 
 targeting  this pathway  are  being  studied.    FDA  approved  anti-IL-17 therapies    include    
secukinumab    and    ixekizumab. Currently  brodalumab  is  FDA  approved  for  psoriasis only, 
but has shown efficacy in trials for PsA as well.
Tofacitinib  is  an  oral  inhibitor  of  Janus  kinase  that has  demonstrated  efficacy  in  the  treatment  of  PsA  in several  randomized  trials  including patients  with  both an  inadequate  response  to  conventional  DMARDs  and TNFα(alpha) to inhibitors.

Abatacept,   a   selective   T-cell   costimulation   modulator used  in  the  treatment  of  
rheumatoid  arthritis,  has  also shown  benefit  in  patients  with  PsA  in  limited  published 
randomized  trials  and  therefore  became  FDA-approved last year.

Apremilast,  a  phosphodiesterase  4  inhibitor,  is  a  newly targeted   synthetic   DMARD   that  
 induces   suppression of  several  inflammation  mediators  including  IL-2,  IL-12, TNF-α, IFN-γ 
and inducible nitric oxide synthase. Efficacy and  safety  in  PsA  has  been  demonstrated  
through  four multi-centric, randomized trials (PALACE Trials) compared to placebo in patients who 
failed other biological options.

Unfortunately,   evidence-based   guidelines   to   navigate
how these therapies should be used are lacking.   Several 
international   and   national   recommendation   sets   are created such as GRAPPA (figure 1) and 
EULAR, with the aim to help rheumatologists in everyday clinical practice management.     At  this  
time,  drug  choices  are  made according  to  available  safety  data,  presence  of  extra- 
articular  manifestations,  cost  and  patient’s  preference. Information  directly  comparing  all 
 biological  drugs  and assessing the efficacy of treatment options specific for PsA  is urgently 
needed.

Conclusion
The  hope  is  that  in  the  future  PsA  patients  will  be treated earlier and more aggressively 
with targeted drug therapies to escape marked progression of joint damage. Moreover, with effective 
management of the skin and joint disease as well as the  consideration  of  risk  factors for 
comorbidities, it will be reasonable to expect to improve the quality of life and function in these 
patients.

References available upon request.

 

 

 

Run a Half Marathon: Learn How to Prepare

Woman running a marathon while smiling

Run a Half Marathon: New Year’s Resolution

Thank you to everyone who submitted their New Year’s resolution for the Health Goals 2018 project. New Year’s Resolution #1 was submitted by Kelly of Gainesville. Kelly wants to “recover from an ankle injury and complete a half marathon.” 

Dr. Miguel Rodriguez, a SIMED rheumatologist in the Gainesville Arthritis Center, has run numerous marathons. He weighed in on the situation and provided a few tips.

1. Get a good pair of running shoes for your specific foot type. The following shoe stores can evaluate how you run and recommend the right shoes for you:
- The Gainesville Running and Walking Store - http://runningandwalkingstore.com/
- Lloyd Clarke Sports - https://www.lloydclarkesports.com/
- Fit2Run - https://www.fit2run.com/

2. Make sure to warm up and cool down and stretch your feet and ankles.
- Dr. Rodriguez recommends and uses the YOFIT foot stretcher. - http://a.co/i4cKCKN
- If you don’t want to purchase a foot stretcher, you can still stretch your ankle and feet using your surroundings as a tool. For instructions and a video walk-through, visit the New York Road Runners website: http://www.nyrr.org/youth-and-schools/running-start/coaching-videos/high-school/stretches-strength/ankle-stretches

3. Follow a half-marathon training plan.
- There are apps and many available resources online that will prepare you for a half marathon. Dr. Rodriguez suggests using Jeff Galloway’s half marathon training plan: http://www.jeffgalloway.com/training/half-marathon-training/

4. Avoid overeating.Paleo diet food with raw ingredients to prep for a half marathon run
- Running and being more physically active is not an excuse to eat poorly. Stick to a paleo or Whole 30 approach for your food.
The Whole 30 diet focusses on healthy, unprocessed food. People who follow the diet avoid consuming grains, alcohol, added sugar, dairy and other unhealthy foods. You would wait until 30 days after starting the diet to weigh yourself for the first time. Learn more: https://whole30.com
The paleo diet also avoids processed food, dairy, grains and alcohol and focusses on eating food as our ancestors did many years ago. Learn about the paleo diet: https://robbwolf.com/what-is-the-paleo-diet/
- You can also use the slow cooker to make sure you always have food ready. When you increase your activity, you will get hungry. The internet has an abundance of free recipes for whatever you want to eat. One of Dr. Rodriguez’s favorite recipes is Slow Cooker Kalua Pig: http://nomnompaleo.com/post/10031990774/slow-cooker-kalua-pig

5. If you are looking for support, resources are available in the area.
- The Florida Track Club hosts group runs: https://floridatrackclub.wildapricot.org/
- Local running stores also host events: https://www.fit2run.com/store-event-calendar/

With these tips in mind, you will be well on your way to running a half marathon. Remember to take your time and move at your own pace. If you experience any pain, take a break and consult a doctor if necessary. 

To schedule an appointment with Dr. Rodriguez in Gainesville, call (352) 378-5173 or request an appointment online. For an appointment with another rheumatologist, call:
Gainesville: (352) 378-5173
Ocala: (352) 291-0245
Chiefland: (352) 378-5173
Lady Lake (The Villages): (352) 391-6450
Or request an appointment online.

Tai Chi for Arthritic Patients: VIDEOS

Elderly people doing tai chi outside

Tai Chi is a meditative martial art that features slow, gentle movements and deep breathing. It is a series of exercises that flow from one to the other with an emphasis in proper posture. It is meditation in motion.

By SIMED Rheumatologist Dr. Miguel Rodriguez

Low Risk

I recommend tai chi to my patients because it is a low impact exercise that may benefit people with arthritis. There is a low risk of injury for the patients, and most people can do tai chi. Medical evidence on tai chi is difficult to find because people have difficulty studying it in randomized controlled trials. There is also a lack of funding for the studies, but from the research that exists, tai chi has been found to be very beneficial for the aging population.

"A growing body of carefully conducted research is building a compelling case for tai chi as an adjunct to standard medical treatment for the prevention and rehabilitation of many conditions commonly associated with age," says Peter M. Wayne, assistant professor of medicine at Harvard Medical School and director of the Tai Chi and Mind-Body Research Program at Harvard Medical School's Osher Research Center.

Tai Chi For Arthritis Part 1 (Shoulder): 

Highly Beneficial

For patients with arthritis, tai chi improves balance, muscular strength, mobility, flexibility, and psychological health. It also decreases pain and helps prevent falls.

I recommend patients do tai chi at least one hour per week, but they can start at their own pace and increase as tolerated. I think it’s better to start slow and keep doing it over the long term than to overdo it the first day or week and stop.

Tai Chi For Arthritis Part 2 (Neck): 

Starting Tai Chi

Elder Options offers tai chi classes in Gainesville for patients with arthritis and for improving one’s balance. I also recommend watching videos on YouTube and checking out the library, which is a great resource and sometimes has postings on the bulletin board for tai chi.

Who Should and Shouldn’t Do Tai Chi

Patients with arthritis, osteoporosis, recurrent falls, and fibromyalgia would benefit the most from tai chi.

If you have a limiting musculoskeletal problem or medical condition – or if you take medications that can make you dizzy or lightheaded – check with a doctor before starting tai chi. Tai Chi has an excellent safety record, so chances are that you’ll be encouraged to try it. If you feel uncomfortable doing anything, you should stop and talk with your doctor.

In addition to tai chi, patients should stay active, work on their weight and reduce their stress.

Tai Chi For Arthritis Part 3 (Spine):

If you would like to schedule an appointment with Dr. Rodriguez, please call the SIMED Arthritis Center in Gainesville at (352) 378-5173 or request an appointment online.Older woman practicing Tai Chi outside flat design graphic

For an appointment with SIMED Rheumatology in any of our locations, call:
Gainesville: (352)378-5173
Ocala: (352) 291-0245
Chiefland: (352) 378-5173
Lady Lake (The Villages): (352) 391-6450

 

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Arthritis 101: What You Need To Know

Arthritis 101: What You Need To Know

Arthritis is a disease that impacts more than 50 million Americans, making it the number one cause of disability in the country. That means 1 in every 5 adults, 300,000 children and countless families are affected by arthritis. – Arthritis Foundation, 2016

Dr. Miguel Rodriguez of SIMED Arthritis Center breaks down some of the components of how arthritis works and why it’s such a debilitating disease.

How does someone develop arthritis?

“You can break up arthritis into two different types, there is osteoarthritis and inflammatory arthritis. Osteoarthritis is a result of wear and tear that ends up happening as a function of age or it could be a result of long term repercussions of having some type of trauma to the body. For example, if you break your ankle and as it heals you continue to walk on it, you can develop arthritis in your ankle. Then there is inflammatory arthritis which is generally classified as an auto immune disease so that means that someone’s own immune system is reacting against their own joints” says Dr. Rodriguez.

Are there certain predisposition to arthritis?

So again we are breaking it up into two different types of Arthritis. Obesity is a big modifiable risk factor for osteoarthritis. The wear and tear of weight bearing joints can be accelerated by obesity. As we get older, we will all eventually develop osteoarthritis.

Inflammatory arthritis can be passed down genetically from family members. Then there are certain things like Gout, which can be from being overweight or having bad kidney function.

Are there precautions someone can take to reduce their chance of arthritis?

It helps to maintain a healthy lifestyle. Staying active is important to keep your weight down. For every pound you lose, your taking four pounds off the knees.

What are some ways to cope with the symptoms of arthritis?

In general you want to try and stay active. Physical Therapy can be helpful to demonstrate safe exercise and stretches that can help decrease joint pain and improve conditioning. Topical creams can be beneficial for pain relief, and for some people, acupuncture helps.

What types of medications are there for arthritis and what do they do?

With Osteoarthritis you are trying to relieve pain so you start off with over the counter medicine like Tylenol(acetaminophen),which is your safest oral medication. Then you have anti-inflammatory medicines such as, Advil(Ibuprofen) and Aleve(Naproxen). Some of these anti-inflammatories are also available in prescription strength. Then you have opiates for extreme pain associated with osteoarthritis.

We consider rheumatoid arthritis a prototypical inflammatory arthritis. To treat patients, we generally start off with steroids in order to get the inflammation under control. Then we use different medications to keep the inflammation under control while we take away the steroids.

DMARD’s Biologic s are exciting newer medications we use to control the autoimmune reaction either individually or in combination to control their inflammatory arthritis. By getting control of the inflammatory symptoms, we are able to decrease or hopefully get people off their steroids.

What are the symptoms of Rheumatoid arthritis?

Joint swelling is the biggest symptom of rheumatoid arthritis. The joints will be visibly swollen, generally the hands will be most affected. This can really impact your day to day routine. For example, if you have to be at work at 8 o’clock, you may need to get up earlier to wait out the stiffness. The stiffness can last up to an hour after waking up. This is something you can help to differentiate between inflammatory arthritis and osteoarthritis.

What type of doctor should someone go to if they think they are developing arthritis?

You can see a Primary Care doctor if you think you are developing arthritis and they can refer you to see a specialist if need be. Your Primary Care doctor can send you to a rheumatologist, a specialist in arthritis. The Rheumatology works with other specialists if the arthritis results in complications requiring surgery or other interventional procedures.

Is there any research going on for arthritis relief?

There is a lot of research going on for rheumatoid and inflammatory arthritis. For these types of arthritis, they are generally caused by the immune system so there are different ways of working on modulating the system to stop the long term damage from the chronic inflammatory process.

Can arthritis be "cured"?

No unfortunately it cannot be cured. However, the idea is to be able to control the systems. So the rheumatoid arthritis will hopefully become in like diabetes or hypertension in some patients. Which means they will have to take medicine all the time but they won’t have any symptoms, or long term complications.

I understand some of the newer arthritis medications cant be taken by mouth. How are these medications administered?

An infusion room is where patients can receive medicines called biologics which are medicines used to control inflammatory arthritis. These medicines are given through an IV and block specific parts of the immune system that are responsible for the swelling or inflammation that cause rheumatoid arthritis. Many rheumatologist, including here at SIMED arthritis center, have infusion rooms incorporated in their clinics.

Can people develop both types of arthritis?

Yes, people can develop both inflammatory and osteoarthritis. People with inflammatory arthritis continue to age and their joints experience the typical wear and tear that leads to osteoarthritis.

As a Doctor how do you diagnose one over the other?

As a Rheumatologist the most important thing we do is have the patient give us a detailed health history and we do a physical exam. This helps differentiate if the problem is an ongoing issue between inflammatory arthritis and osteoarthritis. The doctor can tell the difference between the two by palpating the stiff joints as well as looking at the pattern of the joints involved.

Dr. Rodriguez encourages you to take control of your arthritis this year! If you’re not sure how to start you can begin by scheduling an appointment with a Primary Care physician or a Rheumatologist today! Click here to request an appointment online.