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VBCR - June 2015, Volume 4, No 3 - CCR Conference Highlights
Chase Doyle

The power of technology is driving breakthroughs in medicine with advances in genomics, proteomics, metabolomics, and informatics, to name just a few. But heterogeneous conditions like psoriatic arthritis require more than just technology—they demand a holistic approach to therapy, with careful consideration and treatment of the totality of disease.

At the 2015 annual Congress of Clinical Rheumatology, Iain B. McInnes, MD, PhD, professor of medicine and director of the Institute of Infection, Immunity and Inflammation at the University of Glasgow, Scotland, said, “I love the fact that we are simplifying our therapeutic approach with the aid of algorithms, but psoriatic arthritis needs to give us pause for thought. I’d like us to think about each tissue compartment, including metabolic and psychological [components]. If we take all of those together, we will offer truly holistic care that really will make a difference for our patients.”

In his own words, psoriatic arthritis is a “dreadful diagnosis.” Although pathologic features of this condition include synovitis, enthesitis, osteitis, and skin and nail diseases, there are other functional deficits too. Patients suffer from vascular and metabolic syndromes, and according to McInnes, it is undoubtedly a psychoneurologic disorder.

There is also the issue of outcome heterogeneity. Dermatologists, for example, give psoriasis the same name when it is phenotypically different. All of this, he said, “really reflects the fact we don’t know how to measure the totality of the disease very well.”

Part of this totality is a psychoneurologic component. A recent imaging study of 12 patients with psoriatic arthritis (excluding those with depression) revealed dysregulation of hippocampal chemical function.

“These patients are depressed, not because of swollen joints or skin problems,” said McInnes, “but because the disease involves the brain. There’s a molecular component of the disorder.”

Conflation with rheumatoid arthritis is also a problem. Despite differences in physiology, genetics, therapeutic response, gender response, and a host of other factors, psoriatic arthritis is often treated as the same condition.

“The big problem for us is that we’ve treated rheumatoid and psoriatic arthritis the same,” said McInnes. “We have to treat them as their own diseases. Psoriatic arthritis must move away from the dogma of rheumatoid and live in its own space.”

Understanding our evolutionary history may help. As McInnes sees it, the complex interrelation of human metabolic and immune systems is an adaptive measure—a byproduct of our hunter-gatherer past—which is why dysregulation of the immune system often leads to some form of metabolic syndrome.

“The immune system uses different immune phenotypes in different parts of the body,” he explained. “Airway responses are different from skin responses, [which] are different from oral responses, [which] are different from intra-organ responses, and there’s a good reason for that—the immune system evolved to deal with the context as well as the nature of the insult.”

Given the variance of phenotypic response, McInnes is skeptical of unified outcome measures, which might overlook key differences, especially for new therapeutic interventions.

“What a tragedy,” he said, “if you gave a new intervention that cleared the skin but missed a holistic outcome measure because you needed to have joints better, as well.”

Finally, McInnes stressed the risks associated with vascular disease in people with psoriatic arthritis, encouraging his fellow rheumatologists to take the lead in reducing morbidity and mortality. “If we were actually to change comorbid risk, we’ll save lives, and we’ll do it very quickly,” he concluded. “The patients’ challenge is the totality of the disease, so we need to find ways of working together, whether it’s rheumatologists, dermatologists, or primary care physicians.”

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Last modified: June 26, 2015
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