Browsing Tag

psoriasis

Journal Club

Is tofacitinib effective in treating psoriatic arthritis?

November 7, 2017
Is tofacitinib effective in treating psoriatic arthritis?

As you can recall, psoriatic arthritis is a type of autoimmune disease that affects people with psoriasis.  In certain cases, it can look like rheumatoid arthritis, but it is very different condition.  Rheumatologists use medications like sulfasalazine, methotrexate, Otezla, as well as multiple TNF inhibitors such as Enbrel and Humira to treat psoriatic arthritis. Other medications include Cosentyx, an interleukin 17 inhibitor, as well as Orencia.

Tofacitinib or adalimumab versus placebo for psoriatic arthritis

Recently, researchers studied whether tofacitinib, also known as Xeljanz, could also give some benefit for people with psoriatic arthritis.  A recent study published in the New England Journal of medicine reported the results of the oral psoriatic arthritis trial (OPAL) Broaden, the phase 3 trial which evaluated the efficacy and safety of tofacitinib and adalimumab, also known as Humira, compared to placebo.  Here are the results.

Methods

Design

  • The study lasted 12 months.
  • Everyone had to be on at least one conventional or non-biologic DMARD such as methotrexate, sulfasalazine, or leflunomide.
  • The trial was a randomized, placebo-controlled, double-blind phase 3 trial.
  • People were randomly assigned to receive the following regimens:
    • Tofacitinib 5 mg taken orally twice daily
    • Tofacitinib 10 mg taken orally twice daily
    • Adalimumab 40 mg subcutaneously once every two weeks
    • Placebo with a switch to 5 mg dose of two presented at month three, or placebo with a switch to 10 mg dose of two presented at month three
  • Everyone had to be on a stable background dose of either, methotrexate, sulfasalazine, or leflunomide.

The trial was sponsored by Pfizer.

Primary and secondary endpoints

  • The two primary endpoints assessed at month three were:
    • The percentage of people who achieved an American College of Rheumatology 20 (ACR20) response
    • And the change from baseline Health Assessment Questionnaire – Disability Index (HAQ-DI).

The ACR20 is a composite measure defined as both improvement of 20% in the number of tender and number of swollen joints, and a 20% improvement in three of the following five criteria: patient global assessment, physician global assessment, functional ability measure [most often Health Assessment Questionnaire (HAQ)], visual analog pain scale, and erythrocyte sedimentation rate or C-reactive protein (CRP).

ACR50 and ACR70 are the same instruments with improvement levels defined as 50% and 70% respectively versus 20% for ACR20

  • Secondary endpoints included the amount of people who achieved an ACR50 or more and an ACR70 or more. The researchers looked at the improvement in people’s psoriasis as well as enthesitis (i.e., inflammation of tendons, ligaments, and bursae).
  • The researchers also looked at x-rays of the hands and feet at baseline and at month 12, to see whether they had worsened on treatment.
  • They assessed safety by means of spontaneous reporting of adverse events – physical examinations, and clinical laboratory test.

Results

Efficacy

373 people completed the trial.

  • At 3 months, ACR20 response was:
    • 50 % in the 5-mg tofacitinib group
    • 61% in the 10-mg tofacitinib group
    • 52% in the adalimumab group
    • 33% in the placebo group
  • At 3 months, the ACR 50 response was:
    • 28% in the 5-mg tofacitinib group
    • 40% in the 10-mg tofacitinib group
    • 33% in the adalimumab group
    • 10% in the placebo group
  • At 3 months, the ACR70 response was:
    • 17% in the 5-mg tofacitinib group
    • 14% in the 10-mg tofacitinib group
    • 19% in the adalimumab group
    • 5% in the placebo group
  • At month 12, 90% among people who received tofacitinib or adalimumab did not show any worsening of their disease on x-ray.
  • Both tofacitinib and adalimumab performed better than placebo
  • They both performed similarly but in all fairness, the study wasn’t powered to accurately compare the two.

Safety

  • At 3 months, the percentage of people with adverse events:
    • 39% in the 5-mg tofacitinib group
    • 45% in the 10-mg tofacitinib group
    • 46% in the adalimumab group
    • 35% in the placebo group
  • At 3 months serious adverse events occurred in:
    • 3% of the 5-mg tofacitinib group
    • 1% of the 10-mg tofacitinib group
    • 1% of the adalimumab group
    • 1% of the placebo group
  • At 12 months, the percentage of people with serious adverse events
    • 7% of people in the 5-mg tofacitnib group
    • 4% of the people in the 10-mg tofacitinib group
    • 8% in the adalimumab group
  • The most common adverse events were sinusitis, upper respiratory tract infections, and headaches.
  • One cardiac arrest happened in the placebo group at month 4, i.e., 1 month after switching to tofacitinib.
  • There were 4 cases of shingles that occurred in the groups receiving tofacitinib.
  • Three cases of cancer occurred: day 1, day 11, and day 231 of the trial.

Conclusion

Tofacitinib is effective in treating psoriatic arthritis at 3 months and after one year of treatment.  The rates of adverse effects are more than placebo but comparable to current standard of care.

References

Mease P, et al. Tofacitinib or adalimumab versus placebo for psoriatic arthritis. 2017 Oct 19;377(16):1537-1550.

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

Diseases and Conditions

Guide to living with psoriatic arthritis: Part 1

September 26, 2017
Psoriatic arthritis is an autoimmune disease that not only affects skin, but also joints

In an earlier post I presented a guide to living with rheumatoid arthritis (RA).  That’s all good if you have RA, but what if your rheumatologist diagnosed you with psoriatic arthritis?  What’s psoriatic arthritis and how is it similar or dissimilar to RA?  This week I’ll present to you Part 1 of a Guide to living with psoriatic arthritis.  I’m going to present this as a three-part series.  Part 1 will cover the basics: what is psoriatic arthritis, the cause, risks, symptoms, diagnosis, and treatment.  In Part 2 I’ll cover prognosis, what to expect, diet and exercise.  In Part 3, I’ll be covering the financial side of psoriatic arthritis: How to get access to medications and how to navigate the complicated world of health insurance.

What is psoriatic arthritis?

Psoriatic arthritis (PsA) is a type of autoimmune inflammatory arthritis that afflicts people who suffer from psoriasis (PsO).  It’s estimated that about 26% of people who suffer from psoriasis will get psoriatic arthritis at one point during their lifetime.  Typically, people develop psoriasis first and then get the arthritis.  In some cases, people develop arthritis first and then get psoriasis but this is a lot less common.   Psoriatic arthritis is one of the more common causes of autoimmune arthritis affecting about 2 to 3% of the population.[1]

What is psoriasis and what are the different types of psoriasis?

Psoriasis is an autoimmune disease that affects the skin.  It typically involves the elbows, knees, and scalp, but you can find it in many other areas.  It typically causes itchiness, burning as well as a stinging sensation.  Psoriasis affects about 2% of African-Americans and affects about 3.6% of Caucasians.  Usually people develop it between the ages of 15 and 35, but it can also happen in very young children and older adults as well.

There are many different types of psoriasis and they are all associated with psoriatic arthritis.

  • Plaque psoriasis
  • Guttate psoriasis
  • Inverse psoriasis
  • Pustular psoriasis
  • Erythrodermic psoriasis (life-threatening type of psoriasis)

Please follow this link to learn more about psoriasis.[2]

What causes psoriatic arthritis?

Like most diseases in rheumatology, we’re not sure.  We do know that there’s a strong genetic and environmental part to psoriatic arthritis.  Here are some genetic associations.

  • HLA-Cw6 is associated with severe early onset skin psoriasis
  • HLA-B38 and HLA-B39 are associated with psoriatic arthritis
  • HLA-B27 is associated with psoriatic arthritis that affects the spine.

Although genes do play a part in psoriatic arthritis, most people who have psoriatic arthritis have no genetic risk factors.

The Koebner Phenomenon

Have you ever heard of the Koebner phenomenon?  This phenomenon describes a new skin lesion in an area where healthy skin was injured.  For example, let’s imagine that you have psoriasis.  A mosquito comes along and bites you, it itches, so you scratch.  Then, about 10 days later, you notice that you’ve developed psoriasis in the area you scratched.  That’s the Koebner phenomenon.[3]

Now try to imagine the Koebner phenomenon involving joints.  It’s thought that about 25% of people who get psoriatic arthritis develop the condition after trauma to a joint.  We call this the deep Koebner phenomenon.[4]

Ultimately, we still don’t know exactly why people develop psoriatic arthritis.  Our best guess like most autoimmune diseases, is that certain people are born with a predisposition to develop both psoriasis and psoriatic arthritis.  Then, something in the environment triggers the disease to “come online”.

Does everyone with psoriasis get psoriatic arthritis?

No.  A recent Japanese study tried to find certain risk factors that predispose patients with psoriasis to develop psoriatic arthritis.  First, they found that about 17% of people with psoriasis also had psoriatic arthritis.   Second, they found that people who had psoriasis involving their nails had a higher chance of having psoriatic arthritis: 29% (PsO) versus 62% (PsA).  Interestingly, they also found that people who had high uric acid levels also had a higher risk of having psoriatic arthritis 9% (PsO) versus 22% (PsA).[5]

As a side note, when uric acid levels are high, this increases the risk of gout.

How does psoriasis affect the nails?

Nail psoriasis is very common.  It ranges from about 50% to 87% of people who have psoriasis.  Now, nail psoriasis can present in many ways depending on the anatomic site of the psoriasis inside the nail.  First, a bit of anatomy.

Nail anatomy

 

The nail consists of the nail fold, the nail matrix, and the nail bed.  The nail fold is where the blood vessels supplying the nail come from.  They can be compromised in many diseases such as scleroderma.  The nail matrix is responsible for formation of the nail plate and the nail bed is responsible for attaching the nail plate firmly in place.

Anatomy of the nail

 

When psoriasis affects the nail matrix.  It can cause pitting, crumbling, white spots and red spots in the lunula.  When psoriasis affects the nail bed, it can cause splinter hemorrhages and splitting of the nail from the nail bed (onychyolysis).[6]  Please click the following link to learn more about nail psoriasis + pics.

Please note that none of the features of nail psoriasis are exclusive to psoriasis.  Other diseases can cause these, including:

  • Reactive arthritis
  • Alopecia areata
  • Chemical dermatitis
  • Pemphigus vulgaris.
  • Incontinentia pigmenti

How is psoriatic arthritis different from rheumatoid arthritis?

Although both psoriatic arthritis and rheumatoid arthritis are both autoimmune diseases that affect joints, they are both distinct diseases.  It isn’t simply because you have psoriasis and inflammation in your joints, that you have psoriatic arthritis. Many people with psoriasis have rheumatoid arthritis.  Psoriatic arthritis and rheumatoid arthritis have their own pathophysiology, epidemiology, and symptoms.  Although they do share many treatment options, they also have some medications tailor-made for them.

Here some of the main clinical differences between psoriatic arthritis and rheumatoid arthritis.

  Psoriatic arthritis Rheumatoid arthritis
Joint distribution Asymmetrical Symmetrical
Joint involvement DIP, dactylitis MCP, PIPs, wrists, and MTPs
Involvement of the spine Common Rare, involves the cervical spine
Labs* RF and CCP antibody negative RF and/or CCP antibody positive

* RF = rheumatoid factor, CCP = Cyclic citrullinated peptide antibodies

As you’ll see later on, it’s a lot more complicated that.  Many people presenting with psoriatic arthritis present almost exactly like rheumatoid arthritis.  Here were a few other features that favor a diagnosis of psoriatic arthritis.

  • Presence of nail pits
  • When there is inflammation of the distal interphalangeal joints (Tip of your finger) without any evidence of osteoarthritis
  • “Sausage digits” = dactylitis. This happens when the tendons that supply of the fingers and toes get inflamed.
  • Any inflammation of tendons and ligaments, such as Achilles tendinitis and plantar fasciitis.
  • When there is a family history of psoriasis or psoriatic arthritis, particularly in a first-degree relative. That mom, dad, kids and siblings.
  • The spine is involved.

What are the symptoms of psoriatic arthritis?

If you’re experiencing joint pain and you have a history of psoriasis, particularly psoriasis that involves your nails, you need to think about psoriatic arthritis.  So what do I mean by joint pain?  When it comes to joint pain, what I really mean is, autoimmune or more specifically, inflammatory joint pain.

Psoriatic arthritis can affect almost any joint: knuckles, wrists, toes, knees, shoulders, elbows, hips, and the spine.  Mechanical joint pain is very different from inflammatory joint pain.  Let me explain.

Peripheral inflammatory joint pain

Peripheral joints include all joints except those involving the spine.  When there is inflammation in a peripheral joint, typically people experience pain, swelling, and stiffness, particularly in the morning that lasts at least an hour.  Sometimes they do see some redness and the joints may feel hot at times.  Often times, people also feel a lot more tired than usual, and they can even run low-grade fevers.

Axial inflammatory joint pain

Axial joints are those that involve the spine.  Inflammation involving the back causes symptoms that are very different from your usual mechanical back pain.  Here are some of the following key characteristics:

  • Back pain present for more than three months.
  • Pain improves with exercise.
  • Pain improves with anti-inflammatory medications like naproxen or ibuprofen.
  • Rest usually worsens the pain.
  • Back pain that wakes you up during the second half of the night.
  • Pain and prolonged stiffness in the morning, typically lasting more than an hour.
  • Alternating deep buttock pain.

Enthesitis

Enthesitis means inflammation of connective tissue that attaches to bones.  These include tendons, ligaments, and bursae.  Most cases of enthesitis are caused by injury or overuse.  Think of a marathon runner with Achilles tendinitis or a tennis player with tennis elbow.  In psoriatic arthritis, the immune system attacks these connection points.  So you can have someone who leads a fairly sedentary life with Achilles tendinitis on both feet, runner’s knee, and plantar fasciitis happening all at once, for no good reason.  Not a pleasant experience.

Uveitis

Uveitis is a general term that we use to describe a group of inflammatory diseases that cause inflammation in many parts of the eye: uvea, lens, retina, optic nerve, and the vitreous.  Depending on where the inflammation is happening, your ophthalmologist may describe it as anterior uveitis, intermediate uveitis, posterior uveitis, or panuveitis.

Uveitis is associated with many diseases including psoriasis and psoriatic arthritis.  Sometimes uveitis is the first manifestation of psoriatic arthritis.  This is why I’ve included this topic here, even though technically it isn’t arthritis.  It’s important to know and keep in the back of your mind.[7]

Patterns of disease

Just like rheumatoid arthritis, psoriatic arthritis, can manifest in many ways.  For those of you who want to get really technical, I’ve included a table describing the most common ways psoriatic arthritis presents.

Subtype Percentage Typical joints
Asymmetric oligoarticular* disease 15-20% DIP joints and PIP joints of the hands and feet.  MCP joints, MTP joints, knees, hips, and ankles.#
Predominant DIP involvement 2-5% DIP joints
Arthritis mutilans$ 5% DIP and PIP joints
Polyarthritis! “rheumatoid–like” 50-60% MCP joints, PIP joints, and wrists.
Axial involvement only (spine) 2-5% Sacroiliac joints, vertebral
Enthesitis predominant Tendons and ligaments[8]

* oligoarticular = 2 – 4 joints

# DIP = distal interphalangeal joints, PIP = proximal interphalangeal joints, MCP = metacarpophalangeal joints, MTP = metatarsophalangeal joints

$ Mutilans = severely deformed

! Polyarthritis = 5 or more joints involved

How is psoriatic arthritis diagnosed?

We currently use the CASPAR criteria to make the diagnosis of psoriatic arthritis.  You need three points to get the diagnosis because having 3 or more points has a 99% specificity and 92% sensitivity for the diagnosis of psoriatic arthritis.  Obviously, there are exceptions as the CASPAR criteria are predominantly used for research purposes.

As you can see, you don’t need to have psoriasis to get a diagnosis of psoriatic arthritis.  I know this sounds counterintuitive.

CASPAR classification criteria

  • Evidence of psoriasis (current, past, family)
    • 2 points if current
    • 1 point if history of psoriasis or family history
  • Psoriatic nail dystrophy = 1 point
  • Negative rheumatoid factor = 1 point
  • Dactylitis = 1 point
  • X-ray changes = 1 point

HLA-B*27 antigen

Unlike rheumatoid arthritis, we do not have blood tests to help with the diagnosis of psoriatic arthritis.  At times, your rheumatologist may order something called a HLA-B*27 test.

HLA-B*27 is a genetic test. The majority of people who have a positive HLA-B*27 are perfectly healthy. HOWEVER, having a positive HLA-B*27 can put you at increased risk of developing what we call spondyloarthritis-associated diseases. This is a family of autoimmune diseases. They include:

  • Ankylosing spondylitis, now called axial spondylitis
  • Peripheral spondyloarthritis
  • Reactive arthritis
  • Psoriasis
  • Psoriatic arthritis
  • Uveitis
  • Crohn’s disease
  • Ulcerative colitis

Not every person with psoriatic arthritis will test positive for HLA-B*27, however, those that do, have a higher risk of having axial involvement.[9]  This is important to know, because it may affect the medication your rheumatologist recommends.

Is there a cure for psoriatic arthritis?

The simple answer to this question is no.  Psoriatic arthritis is a chronic, lifelong disease.  Although there is no cure for psoriatic arthritis, there are many medications that can help halt or slow down progression: disease modifying anti-rheumatic drugs (DMARD).

Cardiovascular disease and psoriatic arthritis

In recent years, scientists have found an association between cardiovascular disease and many autoimmune diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis, psoriasis, Crohn’s disease, ulcerative colitis, and psoriatic arthritis.  Basically, people who suffer from psoriatic arthritis have a higher risk of developing cardiovascular disease.[10][11]  [12] Unfortunately, they also tend to have more traditional cardiovascular risk factors like high blood pressure, high cholesterol, and diabetes.  [13]On the upside, effective treatment of psoriatic arthritis can decrease this risk.[14]

How is psoriatic arthritis treated?

Like rheumatoid arthritis, psoriatic arthritis is treated with disease modifying anti-rheumatic drugs (DMARDs). These medications are designed to stop or slow down the progression of psoriatic arthritis by targeting the faulty part of the immune system.  Without treatment, psoriatic arthritis, can cause permanent damage to joints, tendons and ligaments leading to functional impairment and a decrease in quality of life.

Which DMARDs are used to treat psoriatic arthritis?

The following are some of the medications that doctors often use to treat psoriatic arthritis.  Your doctor will recommend certain treatments based on the involved joints and organs, as well as severity, allergies, and other medical conditions you may have.

I’ve broken down the different medications into the following broad categories.

Nonsteroidal anti-inflammatory drugs

  • Ibuprofen
  • Meloxicam
  • Naproxen
  • Sulindac
  • Etodolac
  • Diclofenac
  • Indomethacin
  • Celecoxib

Conventional DMARDs

  • Hydroxychloroquine (Plaquenil) – caution as this medication may make psoriasis flare
  • Methotrexate
  • Leflunomide (Arava)
  • Sulfasalazine
  • Azathioprine – rarely used for psoriatic arthritis

Biologics

Tumor necrosis factor – alpha (TNF-alpha) inhibitors

  • Certolizumab pegol (Cimzia)
  • Etanercept (Enbrel)
  • Adalimumab (Humira)
  • Infliximab (Remicade)
  • Golimumab (Simponi)

Interleukin 12 and 23 inhibitors

  • Ustekinumab (Stelara)

Interleukin 17 inhibitors

  • Secukinumab (Cosentyx
  • Brodalumab (Siliq) – not FDA approved for PsA
  • Ixekizumab (Taltz) – not FDA approved for PsA

T cell inhibitors

  • Abatacept

Interleukin 23 inhibitors

  • Guselkumab

Phosphodiesterase 4 inhibitors

  • Apremilast (Otezla)

To read more about treatment for psoriatic arthritis.  Please follow this link.

Biosimilars

Here in the US, we are starting to see biosimilar medications. These are medications that are sort of copied from existing biologic medications.  They are NOT generic medications. The problem with biosimilars is that because of their complexity, it literally is impossible to exactly copy a biologic medication. If you want to learn more about biosimilar medications, please check this article.

Can I stop my medications if I’m feeling better?

No.  Psoriatic arthritis is a life-long disease.  If you’re feeling better, great!  However, it’s probably your medications that are keeping you that way.  If you stop your medications the psoriatic arthritis will likely come back.  Psoriatic arthritis subsides spontaneously in a VERY small subset of people.

If your medication is making you feel sick, talk to your rheumatologist.  They truly have your best interest at mind and they want to find the best treatment for you.

Do not stop your medications without first consulting your rheumatologist.

Next steps

Let’s recap what we’ve learned today.

  • Psoriatic arthritis is an inflammatory arthritis that affects about 26% of people that suffer from psoriasis and affects about 2 to 3% of the population.
  • We know that there is a strong genetic link and environmental component to psoriatic arthritis, but the majority of cases happen spontaneously.
  • People with nail psoriasis have a higher risk of getting psoriatic arthritis.
  • The Koebner phenomenon describes the appearance of a new skin lesion in an area where healthy skin was injured. The same thing can happen in joints.  This is  the deep Koebner phenomenon.
  • Psoriatic arthritis can present in many ways. It can cause peripheral inflammatory arthritis, axial inflammatory arthritis, enthesitis, and uveitis.
  • Doctors use the CASPAR criteria to help make a diagnosis of psoriatic arthritis. You need three points to get the diagnosis because having 3 or more points has a 99% specificity and 92% sensitivity for the diagnosis of psoriatic arthritis.
  • There are no specific tests help make the diagnosis of psoriatic arthritis, however, people that test positive for HLA-B*27 have a higher chance of having psoriatic arthritis in their spine.
  • People with psoriatic arthritis have a higher risk of having cardiovascular disease but treatment can possibly decrease that risk.
  • Psoriatic arthritis is treated with disease modifying anti-rheumatic drugs.

In part 2 of the Guide to living with psoriatic arthritis, I’ll be covering topics such as natural treatments for nail psoriasis and psoriatic arthritis, the FODMAP diet, how to exercise, and strategies on how to reduce stress.   In part 3 of the Guide to living with psoriatic arthritis, I’ll be covering the financial aspect of psoriatic arthritis most notably, health insurance coverage and the prior authorization process for expensive medications.

Stay tuned and please leave your comments below!

Please follow this link to request a rheumatology consultation.

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

References

Sick woman main areas of the human body affected by psoriasis: By ann131313 via Shutterstock

Nail anatomy by  Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. (Own work) [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

[1] Rheumatology secrets, 3rd edition

[2] https://www.psoriasis.org/about-psoriasis

[3] https://www.dermnetnz.org/topics/the-koebner-phenomenon/

[4] Rheumatology secrets, 3rd edition

[5] Tsuruta N, Imaguku S, Narisawa Y.  Hyperuricemia is an independent risk factor for psoriatic arthritis in psoriatic patients. J Dermatol. 2017 Jul 10. doi: 10.1111/1346-8138.13968. [Epub ahead of print]

[6] Manhart R, Rich P. Nail psoriasis. Clin Exp Rheumatol. 2015 Sep-Oct;33(5 Suppl 93):S7-13.

[7] https://nei.nih.gov/health/uveitis/uveitis

[8] Rheumatology Secrets, third edition

[9] Jadon DR, et al. Axial disease in psoriatic arthritis study: defining the clinical and radiographic phenotype of psoriatic spondyloarthritis. Ann Rheum Dis. 2017 Apr;76(4):701-707. doi: 10.1136/annrheumdis-2016-209853. Epub 2016 Dec 2.

[10] Ozkan SG, Yzisiz H. Gokbelen YA, Borlu F, Yazisiz V.  Prevalence of metabolic syndrome and degree of cardiovascular disease risk in patients with psoriatic arthritis. Eur J Rheumatol. 2017 Mar;4(1):40-45. doi: 10.5152/eurjrheum.2017.16052. Epub 2017 Mar 1.

[11] Fernandez-Gutierrez B, et al. Cardiovascular disease in immune-mediated inflammatory diseases: A cross-sectional analysis of 6 cohorts. Medicine (Baltimore). 2017 Jun;96(26):e7308. doi: 10.1097/MD.0000000000007308.

[12] Castaneda S, et al. Cardiovascular morbidity and associated risk factors in Spanish patients with chronic inflammatory rheumatic diseases attending rheumatology clinics: Baseline data of the CARMA project. Semin Arthritis Rheum. 2015 Jun;44(6):618-26. doi: 10.1016/j.semarthrit.2014.12.002. Epub 2014 Dec 25.

[13] Jafri K, Bartels CM, Shin D, Gelfand JM, Ogdie A.  Incidence and management of cardiovascular risk factors in psoriatic arthritis and rheumatoid arthritis: a population-based study. Arthritis Care Res (Hoboken). 2017 Jan;69(1):51-57. doi: 10.1002/acr.23094. Epub 2016 Nov 28.

[14] Agca R, Heslinga M, Kneepkens EL, van Dongen C, Nurmohamed MT. The effects of five-year etanercept therapy on cardiovascular risk factors in patients with psoriatic arthritis. J Rheumatol. 2017 Jun 1. pii: jrheum.161418. doi: 10.3899/jrheum.161418. [Epub ahead of print]

Self-Injection Videos

How to inject methotrexate

September 12, 2017
How to inject methotrexate

Methotrexate is commonly prescribed to treat rheumatoid arthritis, psoriatic arthritis, psoriasis, as well as many other autoimmune diseases. It comes as a pill but in certain situations the medication may be more effective if it’s injected.  That being said, injectable methotrexate comes as a auto-injector pen but due to cost, often times we need to rely on the good old-fashioned method: needle, syringe, and a vial of methotrexate.  First, Dr. Farrell is going to teach us how to inject a vial of methotrexate.  In the second video, she will teach us how to inject with an auto-injector pen.

Preparing for your injection

  • Keep your medication stored in the refrigerator until use
    • Before injecting medication, take the vial out of the refrigerator.
    • Allow it to warm up to room temperature.
  • Pick a place in your house that is clean and has room for your materials (such as the kitchen table).
  • Wash your hands thoroughly with either:
    • Soap & water
    • Hand sanitizer
  • Chose an area to inject – Thigh or Stomach.
    • Chose an area that is intact and clear.
    • It should not have any of the following:
      • Cuts
      • Scrapes
      • Bruises
      • Psoriasis patches
      • If you have extensive psoriasis, inject between patches
      • Moles
      • Scars
    • Please rotate area each time you inject (shown in picture below).

Areas to inject subcutaneous medication

  • Cleanse chosen area
    • Cleanse chosen area with either of the following:
      • Alcohol swab
      • Alcohol and a cotton ball
    • Use the chosen alcohol material to “swipe” area
      • Can either use a circular motion or wipe in “strips”
      • Allow the area to dry

Injecting a methotrexate vial

Drawing the medication

  • If it is your first time using the vial, you will have to remove the plastic cap from the vial
  • Clean the top of the vial with an alcohol swab
  • Open syringe packaging and take syringe out
    • Be careful while doing this – the needle may come apart, so make sure the needle is securely on the syringe before moving on
  • Double check the dosage on your prescription.  Does your doctor want you to inject 0.5 mL? 0.6 mL?
  • Pull plunger to get air into the syringe
    • The amount of air should be half the amount of the dose that you are going to draw up (Example: if you need a dose that is 1 mL of methotrexate, draw up 0.5 mL of air)
  • Press the needle into the vial
    • Should be right into the center of the top of the vial at a 90-degree angle
  • Push the plunger to transfer the air into the vial
  • Flip the vial upside down with the needle still in
  • Pull back on the plunger to draw liquid into the syringe
    • If an air bubble appears into the syringe, push the plunger back up and try pulling out again
    • This may take a few tries before you get only medication into the syringe
  • Once you have withdrawn the dose of the medication that you need, flip the vial and take the needle out

Injecting the medicine

  • Pinch cleansed skin
  • Insert needle into the chosen area at a 45-degree angle
    • You may keep the skin pinched or let go of the skin
  • Push the plunger slowly to inject the medication
  • Once you have injected all of the medication, take the needle out of your skin

After the injection

  • Properly dispose of the entire syringe
    • NEVER recap the needle
    • Sharps Container
      • Can be purchased at your local pharmacy
      • Disposal
        • Hospitals may take full sharps containers, ask first.
        • Pharmacies and Doctors’ offices are not allowed to take used syringes or needles
  • Discard remaining materials in the trash (cap, alcohol swabs, etc.)

Injecting methotrexate with an auto-injector pen

Injecting Otrexup®

  • There will be a number “1” labeled on the auto-injector
    • Twist cap off
  • There will be a number “2” labeled on the auto-injector
    • Press with thumb to flip cap off
  • Place tip of the auto-injector on the skin at a 90-degree angle
  • Press button to release medication
    • Hold for 10 seconds
    • May feel a slight pinch and tingling as the medication goes in

Injecting Rasuvo®

  • There will be a yellow cap at the end that you will pull straight off
  • Place tip of the auto-injector on the skin at a 90-degree angle
  • Press button to release medication
    • Hold for 10 seconds
    • May feel a slight pinch and tingling as the medication goes in

After the injection

  • Properly dispose of the auto-injector.
    • Sharps Container
      • May be provided by the drug company (depending on the medication)
      • Can be purchased at your local pharmacy
      • You may use a coffee can if you are unable to attain a sharps container
      • Disposal
        • Hospitals may take sharps
        • Pharmacies and Doctors’ offices are not allowed to take used syringes or needles
  • Discard remaining materials in the trash (cap, alcohol swabs, etc.)

Credits

Jessica Farrell, PharmD.  Clinical Pharmacist, The Center for Rheumatology/Associate Professor, Albany College of Pharmacy and Health Sciences

With the help of Autumn Koniowka. Doctor of Pharmacy Candidate Class of 2018, Albany College of Pharmacy and Health Sciences, and Megan Phillips. Doctor of Pharmacy Candidate Class of 2018, Albany College of Pharmacy and Health Sciences.

A special thanks to Tammy Garren, PhD. Instructional Designer, Center for Innovative Learning, Albany College of Pharmacy and Health Sciences.

Methotrexate vial image: By Li Wa/Shutterstock

Injection site image: By British Columbia Institute of Technology (BCIT). Download this book for free at http://open.bccampus.ca [CC BY 4.0 (http://creativecommons.org/licenses/by/4.0)], via Wikimedia Commons

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

Diseases and Conditions Self-Injection Videos

How to inject Humira, Enbrel, Simponi, and Cimzia

August 28, 2017
Video demonstrations on how to how to inject Humira, Enbrel, Simponi, and Cimzia

Humira®, Enbrel®, Simponi®, and Cimzia® are medications commonly prescribed for rheumatoid arthritis, psoriatic arthritis, psoriasis, and ankylosing spondylitis.  All of these come in self-injectable pens or pre-filled syringes.  You will be asked to inject these yourself or by a love one, in the comfort of your home.  Today, we’re going to go over how to inject these self-injectable medications.

Preparing for your injection

  • Keep your medication stored in the refrigerator until use
    • Before injecting medication, take the autoinjector out of the refrigerator.
    • Allow it to warm up to room temperature.
  • Pick a place in your house that is clean and has room for your materials (such as the kitchen table).
  • Wash your hands thoroughly with either:
    • Soap & water
    • Hand sanitizer
  • Chose an area to inject – Thigh or Stomach.
    • Chose an area that is intact and clear.
    • It should not have any of the following:
      • Cuts
      • Scrapes
      • Bruises
      • Psoriasis patches
      • If you have extensive psoriasis, inject between patches
      • Moles
      • Scars
    • Please rotate area each time you inject (shown in picture below).

Areas to inject subcutaneous medication

By British Columbia Institute of Technology (BCIT). Download this book for free at http://open.bccampus.ca [CC BY 4.0 (http://creativecommons.org/licenses/by/4.0)], via Wikimedia Commons

  • Cleanse chosen area
    • Cleanse chosen area with either of the following:
      • Alcohol swab
      • Alcohol and a cotton ball
    • Use the chosen alcohol material to “swipe” area
      • Can either use a circular motion or wipe in “strips”
      • Allow the area to dry

The injection

  • Take off the white cap, observe the medication in the window to be sure that it is clear (no cloudiness or crystals.)
    • You will see a small air bubble within the window, this is normal and will not cause harm when injecting
  • Press down firmly on the clean area of skin, so that the pen is flush with the skin (90-degree angle).
    • The pen needle will not eject unless pressed firmly to skin

For Cimzia® and other medications that come in prefilled syringes

  • Pinch the skin around the injection site and insert the needle at a 45-degree angle
  • Press in the plunger slowly

You may notice the plunger is hard to press this is due to the size of the medication, be sure to continue to inject slowly to administer all medication

  • Press button to inject the medication.
    • You may feel a slight pinch as the needle enters your skin, and tingling as the medication is administered
    • If you have trouble pressing the button try lifting the pen off your skin, and repressing the pen firmly to the area
  • Hold for 15 seconds.
    • Window will become colored (yellow) but continue to hold dose for at least 15 seconds to ensure that all medication is administered

What to do after the injection

  • Lift the pen up from skin and place the whole pen into the sharps container.
    • If you do not have a sharps container available, contact your pharmacy/doctor’s office about obtaining one
      • In the meantime, you may use an old coffee container with a lid
    • Some hospitals take full Sharps Containers for disposal. Here at the office we do not. Contact your pharmacy for more information about the disposing of your Sharps Container.
  • Discard remaining materials in the trash (cap, alcohol swabs, etc.)

If you have any concerns about your medication (e.g., excessive pain, swelling, redness bruising, bleeding, fever, breathing problems), please contact your rheumatologist.

For more information

Humira® – Abbvie

Enbrel® – Amgen

Simponi® – Janssen

Cimzia® – UCB

Jessica Farrell, PharmD.  Clinical Pharmacist, The Center for Rheumatology/Associate Professor, Albany College of Pharmacy and Health Sciences

With the help of Autumn Koniowka. Doctor of Pharmacy Candidate Class of 2018, Albany College of Pharmacy and Health Sciences, and Megan Phillips. Doctor of Pharmacy Candidate Class of 2018, Albany College of Pharmacy and Health Sciences.

A special thanks to Tammy Garren, PhD. Instructional Designer, Center for Innovative Learning, Albany College of Pharmacy and Health Sciences.

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

Diseases and Conditions Overcoming Inflammation

Simple and easy ways to hydrate your skin

January 23, 2017

This past Christmas, I received probably one of the most bizarre gifts I have ever received.  A full adult-sized onesie! Let me tell you, it hasn’t really brought out the most flattering bit of my anatomy.  Last year I had lamented that my house was kind of cold in the winter and mentioned that babies had it made with their one-piece pajamas.  That being said, I decided to use my family’s superhuman memory to my advantage.  This year it was all about my dry skin and how wonderful it would be to have a paraffin wax machine.

I have to admit it though, that onesie does keep me nice and toasty at night!

While waiting for the paraffin wax machine that hopefully will be making its apparition Christmas 2017, hint-hint, I thought I’d do a little research about the topic of dry skin: anatomy, immunology, and basically how to keep it as moist as possible without that oily feeling.  People who suffer from autoimmune diseases tend to suffer from dry skin.  This really isn’t surprising.  This skin is the largest organ in the human body.  Because of its large surface area, it needs a large complex immune system.  Autoimmune diseases = inflammation and inflammation involving the skin = dryness, irritation, and itchiness.

Anatomy and immunology

The medical term for dry skin is xerosis and the term dermatitis signifies inflammation of the skin.  The skin is made up of the epidermis which is the most superficial layer followed by the dermis and then the subcutis.  These layers are made up of blood vessels, hair follicles, as well as glands.  One of the main functions of the skin is to protect your body from the outside world.  That being said, the skin contains many immune cells such as Langerhans cells, neutrophils, eosinophils, and lymphocytes.  When skin is irritated by bacteria, viruses, chemicals, the immune system kicks in to fight off the foreign invader.  With autoimmune diseases, it’s the immune system that starts to attack the skin itself.  In either case, when the immune system is activated it causes inflammation which = irritation + dryness.

There are many autoimmune diseases that affect the skin.  Some of these include scleroderma, Sjögren’s syndrome, rheumatoid arthritis, lupus, sarcoidosis, and psoriasis.

So what can you do to keep your skin moist and healthy? Drink plenty of water, limit the amount of exposure of your skin to water, protect your skin from the sun, avoid allergens, and moisturize regularly.

Avoiding irritation and dehydration

You would think that more water equals more hydration.  That may be true for ingested water, but it’s the opposite for water that makes direct contact with your skin.  For example, every healthcare worker soon learns that there is a positive correlation between the dryness of their hands with the amount of times they wash their hands per day.  Don’t get me wrong washing your hands is very important to prevent the spread of infection, but it certainly does a number to your skin.  Some things simply cannot be avoided.  That being said, if you suffer from dry skin, try to limit the amount of time you spend washing in the shower.  Make it a quick 5 min instead of a long 30 min shower.  Another tip is to use lukewarm water instead of hot water.

For people who shave, try to shave immediately after you shower.  The hair will be much more malleable at this time.  Always use a sharp razor and always shave with the line the hair grows.  These will lessen the amount of irritation caused by shaving.

This may sound obvious, but it’s really important to prevent your skin from burning.  Burnt skin = dehydration.  If you plan on being in the sun, try to stay in the shade between 11 AM and 3 PM.  The UV is at its highest during these hours.  Aim to cover up with clothing made of light-colored cotton.  Light colored clothing adds a few extra SPF points.  Broad-brimmed hats and sunglasses are your friends.  Use sunscreen liberally.  At least 15 SPF.  For people suffering from lupus, plan for a much high SPF as UV can actually trigger a full-fledged systemic flare.

What I mean by avoiding allergens means, try to avoid anything that may cause some form of allergic reaction.  Again allergic reaction = inflammation = deterioration of skin barrier function = dehydration.  Obviously, it’s impossible to avoid everything but it may be a good idea to swap perfumed household products for hypoallergenic ones: laundry detergent, softener, soap, shampoo, moisturizer etc.  Anything that directly or indirectly makes contact with your skin.  It’s important to note that even, “all natural” products can potentially contain allergens.  For example, most people aren’t allergic to Shea butter, but some are.  Learn to know your skin.

Hydrate you skin

Are you as confused as I am when it comes to moisturizers?  Which ones are good?  Which ones are bad?  What’s the difference between a lotion, cream, and an ointment?  What goes where?  How much should I apply?  How often?

It’s essential to moisturize daily particularly those suffering from dry skin conditions.  Simply put, dry skin is determined by the amount of transepidermal water loss and this in term is determined on the integrity of the skin barrier function.  The composition of the moisturizer determines whether the treatment helps skin barrier function or not.  I can’t tell you which moisturizer is better than the other, because I haven’t found any blinded head-to-head evidence-based studies addressing this topic.  If you do find one, let me know.  I’m all ears!

Moisturizers come in various forms: lotions, creams, and ointments.  Lotions are the least greasy and ointments are the greasiest.  Typically, the greasier the moisturizer, the longer it lasts.  The questions what goes where and how often and how much to apply, may actually be over-complicating the matter.  The goal is to keep the skin nice and hydrated.  When you really think about it, consistency is key.  Would you wear a thick greasy ointment on your hands all day long?  I wouldn’t because it’s uncomfortable and quite frankly not practical.  Due to my job description, I wash my hands nearing 100 times a day.  I’d rather use a cream or lotion and simply apply it more often.  The ointment might be better tolerated at night before going to bed?  If I’m comfortable, I’m more likely to wear the moisturize regularly.  How much to apply?  Apply enough so that the skin feels moist.

Like I said, there’s no need to complicate things.

One word of advice, when applying a moisturizer, try to stoke it onto the skin in the direction that the hair naturally falls.  This can prevent folliculitis.

Caution

A little bit about miracle cures.  They don’t exist.  Any product marketing itself to be a “cure for psoriasis”, is probably a product to be avoided.   A lot of these products have high doses of corticosteroids, which may initially make the skin look more hydrated and look “healthier”.  If you suffer from psoriasis, it may even clear it up.  But in the long run, regular application will cause permanent skin thinning, aging, and atrophy.  Just like food, read the ingredients on the packaging of your moisturizer.

When it comes to diet, in general beware of any diet advocating cutting out lists of foods.  For the most part, these are not founded in evidence and you actually may be doing more harm than good.  Nothing beats a clean diet and plenty of water.  What that actually means, is a matter up for debate.  For more information regarding clean eating, I recommend visiting the Blue Zone Project by Healthways.  The Blue Zone principles were derived from a National Geographic study identifying practices in cultures where people tend to live longer, i.e., greater than 100 years of age, and healthier as compared to the normal population.  When you have entire populations of people living longer and healthier over  thousands upon thousands of patient years, it makes me think they’re onto something.

Parting words

I hope you’ve found this information useful.  If you would like more information, please contact your local physician.  Love your skin, keep it nice and hydrated!

References

Dermatology Secrets Plus, 5th edition copyright 2016 by Elsevier

American Academy of Dermatology

Loden M. Effect on moisturizers on epidermal barrier function. Clin Dermatol. 2012 May-Jun;30(3):286-96.

Penzer R. Providing patients with information on caring for skin. Nurs Stand. 2008 Nov 5;23(9):49-56.

Subscribe

Enter your email address to receive notifications of new posts.