Approach to management and symptomatic (including non-pharmacologic) management of psoriatic arthritis

2018 ◽  
Author(s):  
Laura Acosta Felquer ◽  
Enrique R. Soriano
Keyword(s):  
Psoriatic Arthritis ◽  
Early Diagnosis ◽  
Treatment Options ◽  
Collaborative Management ◽  
Treat To Target ◽  
High Grade ◽  
Number Of Patients ◽  
Pharmacologic Management ◽  
Inflammatory Drugs ◽  
Surgery Outcomes

Psoriatic arthritis (PsA) is a heterogenous disease with multiple manifestations and comorbidities, and requires a collaborative management with other specialists. The major symptoms bordering patients are pain stiffness, and swelling, but fatigue, depression, embarrassment and fear are frequent and not always assessed by treating physicians. Non-steroidal anti-inflammatory drugs and local glucocorticosteroid injections remain important treatment options that should be used, although with caution, in the appropriate patient. Since the pre-biologic era, physical therapy has been part of non-pharmacological treatment in patients with rheumatic disease. Unfortunately there is little evidence of the efficacy of rehabilitation in PsA with no study with high grade of evidence. Surgery should be reserved for advanced cases as the new paradigms in the treatment of PsA (early diagnosis and treatment, remission as an objective, and treat to target), would very probably reduce the already low number of patients that need this last treatment option. In PsA patients surgery outcomes are similar to those of surgical management of other forms of arthritis. Symptomatic and non-pharmacologic management of PsA remain as important adjuvants of PsA treatment, although with little evidence.

scholarly journals Beyond the guidelines management of juvenile idiopathic arthritis: a case report of a girl with polyarticular disease refractory to multiple treatment options and Leri Weill syndrome

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Vana Vukić ◽  
Ana Smajo ◽  
Mandica Vidović ◽  
Rudolf Vukojević ◽  
Miroslav Harjaček ◽  
...  
Keyword(s):  
Juvenile Idiopathic Arthritis ◽  
Case Report ◽  
Treatment Options ◽  
Janus Kinase ◽  
Musculoskeletal Symptoms ◽  
Multiple Treatment ◽  
Number Of Patients ◽  
Systemic Glucocorticoids ◽  
Inflammatory Drugs ◽  
Anti Inflammatory

Abstract Background The last two decades brought new treatment options and high quality guidelines into the paediatric rheumatologic practice. Nevertheless, a number of patients still present a diagnostic and therapeutic challenge due to combination of vague symptoms and unresponsiveness to available treatment modalities. Case presentation We report a case of sixteen years old girl suffering from polyarticular type of juvenile idiopathic arthritis refractory to multiple treatment options. She first presented at the age of 4 with swelling and contractures of both knees. Her symptoms were initially unresponsive to nonsteroidal anti-inflammatory drugs and progressed despite treatment with intraarticular and systemic glucocorticoids and methotrexate. Throughout the years, she received several biologics together with continuous administration of nonsteroidal anti-inflammatory drugs and disease modifying anti-rheumatic drugs as well as intraarticular and systemic glucocorticoids in disease flares. However, none of this options  provided a permanent remission, so various other modalities, as well as other possible diagnoses were constantly being considered. Eventually she became dependent on a daily dose of systemic glucocorticoids. In 2018, the treatment with Janus kinase inhibitor tofacitinib was initiated, which led to gradual amelioration of musculoskeletal symptoms, improvement of inflammatory markers and overall well-being, as well as to the weaning of systemic glucocorticoids. As the swelling of the wrists subsided for the first time in many years, Madelung’s deformity was noticed, first clinically, and later radiographically as well. Genetic analysis revealed short-stature homeobox gene deficiency and confirmed the diagnosis of Leri Weill syndrome. Conclusions This case report emphasizes the need for reporting refractory, complicated cases from everyday clinical practice in order to build-up the overall knowledge and share experience which is complementary to available guidelines. Individual reports of difficult to treat cases, especially when additional diagnoses are involved, can be helpful for physicians treating patients with common rheumatological diseases such as juvenile idiopathic arthritis.

Single-agent bevacizumab for recurrent high-grade glioma.

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. e13019-e13019
Author(s):  
Megan Greally ◽  
Karen Anne Cadoo ◽  
Niamh Coleman ◽  
Michelle O'Brien ◽  
Lynda M. O'Riordan ◽  
...  
Keyword(s):  
Performance Status ◽  
Treatment Options ◽  
Single Agent ◽  
Tumour Response ◽  
Therapeutic Interventions ◽  
High Grade ◽  
Steroid Use ◽  
Mixed Response ◽  
Number Of Patients ◽  
Radiological Response

e13019 Background: High grade gliomas(HGG) are aggressive primary brain tumors. Most patients relapse following adjuvant therapy and treatment options are limited. Novel therapies have impacted little on overall survival (OS). Bevacizumab is approved for use following recurrence. We aimed to evaluate the extent of clinical benefit derived from this treatment, as defined by decreased steroid usage and median OS. Methods: We retrospectively reviewed medical records of consecutive patients with recurrent HGG treated with single agent Bevacizumab from May 2009 to Dec 2012 at our institution. We recorded patient demographics, histological features, therapeutic interventions, OS, steroid use and radiological response. Results: 29 patients with recurrent glioma were identified, 19 male and 10 female, with a median age at diagnosis of 47 years (16-72). All patients developed tumour recurrence following various combinations of multimodal therapies including 1-3 partial debulking surgeries, radiotherapy and chemotherapy. The median time from diagnosis of HGG to commencement of bevacizumab was 15 months (6-42). Patients received a median of 7 cycles (1-22) of therapy on a variable dosing schedule. 4 patients are alive, 2 continue on Bevacizumab. 19 patients were on steroid therapy when commencing therapy. There was a significant reduction in mean daily steroid use during therapy (7.65mg vs 3.97mg, p = 0.012). However, daily steroid use ultimately increased in some patients following treatment failure. Interval imaging appearances improved in 6 cases, deteriorated in 15, were stable in 4 and 1 patient had a mixed response. 1 patient was not re-imaged due to deterioration in performance status on therapy. The median OS was 5.5 months (0.5-16 months) from commencement of bevacizumab. Conclusions: The management of patients with recurrent HGG is challenging and prognosis remains dismal. In our unselected cohort, Bevacizumab therapy resulted in temporary or sustained steroid reduction in a majority. However, only a small number of patients demonstrated an objective radiological response and median OS was poor. Tumour response was variable and the addition of a predictive biomarker to establish which patients are likely to benefit from treatment may be helpful.

Retrospective review of safety and efficacy of checkpoint inhibition in refractory high-grade gliomas.

2017 ◽  
Vol 35 (15_suppl) ◽  
pp. 2033-2033 ◽  
Author(s):  
Samantha Reiss ◽  
Prakirthi Yerram ◽  
Lisa Modelevsky ◽  
Christian Grommes
Keyword(s):  
Treatment Options ◽  
Single Agent ◽  
Progression Free Survival ◽  
Median Number ◽  
Cancer Center ◽  
High Grade ◽  
Concomitant Therapy ◽  
Safety And Efficacy ◽  
Number Of Patients ◽  
High Grade Gliomas

2033 Background: Treatment options for refractory high grade gliomas (HGG) are limited. Programmed cell death ligand-1 (PD-L1) expression has been reported in 0-61% of HGGs and therefore might be a suitable target in HGG. The purpose of this study was to describe safety and efficacy of PD-1 inhibition in patients with refractory HGGs. Methods: This IRB approved single center retrospective study at Memorial Sloan Kettering Cancer Center included pathologically confirmed HGG with an age ≥18 years who received a PD-1 inhibitor between 9/2014 and 10/2016 outside of a clinical trial. Results: Twenty five HGGs were identified. All patients received the PD-1 inhibitor pembrolizumab (pembro) as part of compassionate use. Median age was 49 years (range 30-72); 44% were men; 13 had glioblastoma (52%), 7 anaplastic astrocytoma (28%), 2 anaplastic oligodendroglioma (8%), 2 unspecified HGG (8%), and 1 gliosarcoma (4%). Patients received a median of 4 prior lines of therapy (range 1-9). Nineteen (76%) previously failed bevacizumab. Median baseline KPS was 80 (range 50-100). Concurrent treatment included bevacizumab in 17 (68%) or bevacizumab and temozolomide in 2 (8%) patients. Median number of doses administered was 3 (range 1-14). Treatment toxicity and response was assessed in 24 patients. PD-1 inhibitor related adverse events (AEs) included LFT elevations (33%), hypothyroidism (17%), diarrhea (17%), myalgias/arthralgias (13%), and rash (8%). Other common AEs were hyperglycemia, fatigue, thrombocytopenia, lymphopenia, headache, and nausea in the setting of concomitant therapy and additional supportive care (dexamethasone). Grade 3 AEs included seizure (4%), headache (4%), nausea (4%), and vomiting (4%). Best radiographic response was partial response (n = 2), stable disease (n = 5), and progressive disease (n = 17). Median progression free survival (PFS) was 42 days (range 7-282) and median overall survival was 121 days (range 15-415). Three patients (12%) had a PFS > 90 days; of these, 2 received single agent pembro. Conclusions: Patients with HGG had low response rates. However, a small number of patients had prolonged PFS. Pembro was tolerated with few serious AEs, even in patients receiving concomitant therapy.

scholarly journals Use of a multidimensional RAPID3 questionnaire to assess the achievement of remission and minimal disease activity in patients with early psoriatic arthritis treated according to Treat-to-target strategy

2019 ◽  
Vol 56 (6) ◽  
pp. 739-745
Author(s):  
E. Yu. Loginova ◽  
T. V. Korotaeva ◽  
A. D. Koltakova
Keyword(s):  
Psoriatic Arthritis ◽  
Disease Activity ◽  
Combined Therapy ◽  
Treat To Target ◽  
Tender Joint Count ◽  
Minimal Disease Activity ◽  
Open Label ◽  
Number Of Patients ◽  
Minimal Disease ◽  
Target Strategy

The current Treat-to-target (T2T) strategy in the management of patients with psoriatic arthritis (PsA) is based on strict control over the dynamics of a patient's status and timely correction of therapy according to the presence or absence of remission or minimal disease activity (MDA) within 6 months after treatment initiation. The multidimensional RAPID3 questionnaire based on the patient's own opinion of his/her health status, has demonstrated its high effectiveness in assessing remission in patients with rheumatoid arthritis (RA). The possibilities of using the RAPID3 questionnaire in patients with early PsA (ePsA) with T2T strategy have not yet been studied.Objective: to investigate whether the multi-dimensional RAPID3 questionnaire may be used to assess the achievement of remission and MDA in ePsA patients with a T2T (Treat-to-target) strategySubjects and methods. The investigation enrolled 61 patients (29 men and 32 women) with ePsA meeting the 2006 CASPAR criteria; the mean age of the patients was 37±10.6 years; the duration of PsA and psoriasis was 11.3±10.2 and 75.4±80.9 months, respectively. The patients were followed up for 12 months during the open-label REMARCA study performed by the T2T principles. At baseline, all the patients were given methotrexate (MTX; Methoject) subcutaneously at a dose of 10 mg/week, with escalation by 5 mg every 2 weeks up to 20–25 mg/week. If there was no low disease activity (LDA), DAS28/DAS remission, or MDA after 3 months, the patients received combined therapy with MTX 20–25 mg/week and adalimumab (ADA) or ustekinumab (UST) at standard doses. All the patients underwent standard rheumatologic examination before therapy and every 3 months. The investigators calculated tender joint count (TJC) among 78 joints; swollen joint count (SJC) among 76 joints, the Ritchie articular index, and the number of entheses by the Leeds Enthesitis index (LEI). Joint pain measurement, patient (PGA) and physician (PhGA) global assessment on visual analog scale (VAS) was performed, the serum level of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were evaluated. DAS and DAS28, HAQ and RAPID3 functional index were estimated. The number of patients achieving LDA, DAS/DAS28 remission, and MDA were determined. Results and discussion. At 1 year of therapy, 36 (59%) out of the 61 patients and 25 (41%) out of the 61 patients were treated with MTX and this drug in combination with ADA or UST, respectively. After 1 year of treatment, the whole group displayed a significant improvement of all PsA activity parameters as compared with baseline values: DAS, 3.93 [3.20; 4.58] / 1.36 [0.82; 2.25], SJC, 7 [5; 11] / 1 [0; 3], TJC, 8 [6; 1] / 1 [0; 3], PhGA, 56 [48; 69] / 10 [5; 20] and VAS pain, 54 [48; 68] / 11 [1; 20], PGA, 55 [49; 68] / 14 [7; 24], HAQ, 0.75 [0.50; 1] / 0 [0; 0.63], respectively. There was a significant correlation of RAPID3 with PsA activity and CRP. MDA was seen in 43 (70.5%) out of the 61 patients. Among the patients who had achieved MDA, the RAPID3 values corresponded to remission, but were significantly higher in the patients who had not attained MDA: 2.5 [1.3; 5.3] and 8.1 [6.0; 15.1], respectively. RAPID3 demonstrated high sensitivity in assessing the achievement of remission, LDA, and MDA in patients with ePsA.Conclusion. RAPID3 based on a patient's personal opinion of his/her disease is a simple and reliable tool to assess the disease activity in patients with ePsA and to monitor the efficiency of therapy with a T2T strategy and may be really useful in practice.

scholarly journals The burden of psoriatic arthritis in the biological era: data from the Belgian Epidemiological Psoriatic Arthritis Study (BEPAS)

Rheumatology ◽  
2021 ◽  
Author(s):  
Kurt de Vlam ◽  
Serge Steinfeld ◽  
Adrien Nzeusseu Toukap ◽  
Filip van den Bosch ◽  
Rik Joos ◽  
...  
Keyword(s):  
Psoriatic Arthritis ◽  
Clinical Data ◽  
Treatment Options ◽  
Patient Reported Outcome Measures ◽  
Actual State ◽  
X Rays ◽  
Number Of Patients ◽  
Patient Reported ◽  
T1 And T2 ◽  
The Impact

Abstract Objectives To characterize the frequency of PsA subtypes, as well as to estimate the severity based on damage and inflammation, and to estimate the impact of PsA on patients’ health-related quality of life. Methods Longitudinal observational study in 17 academic and non-academic centres in Belgium. Patients with PsA fulfilling CASPAR criteria were recruited. Three visits were scheduled: at baseline (T0), at one year (± one month) (T1) and at two years (± one month) (T2) of follow-up. Demographics, clinical data and patient reported outcome measures were collected at T0, T1 and T2. X-rays of hand and feet were collected yearly (T0, T1 and T2). X-rays of the spine were collected at T0 and T2. Here we report on the burden of disease based on the clinical data and patient reported outcomes. Results 461 patients were recruited. 73.5% have combined peripheral and axial involvement. 13.7% had hip involvement. Plaque psoriasis was predominant (83.9%). At inclusion respectively 42.7% and 58.8% had no tender or swollen joints. Dactylitis and enthesitis were still present in 13.7% and 24.1% of the patients respectively. 68% and 44,2% of patients was treated with DMARD’s and/or anti TNF, respectively. Forty-three percent of the patients had a state of minimal disease activity and 62% considered the actual state as satisfactory (PASS). The mean HAQ score was 0.7% with 32.5% of patients who had score normal score (<0.3). Conclusion Despite the availability of different treatment options, including biologicals (anti-TNF), still a substantial number of patients have active disease and have a high disease burden.

Pulmonary Manifestations in Rheumatoid Arthritis, Psoriatic Arthritis and Peripheral Spondyloarthritis Prevalence, Diagnostic Approach and Treatment Options

2020 ◽  
Vol 16 ◽  
Author(s):  
Daniel Dejcman ◽  
Valentin Sebastian Schäfer ◽  
Dirk Skowasch ◽  
Carmen Pizarro ◽  
Andreas Krause ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Psoriatic Arthritis ◽  
Lung Disease ◽  
Current Knowledge ◽  
Treatment Options ◽  
Pulmonary Diseases ◽  
Chronic Obstructive ◽  
Pulmonary Manifestations ◽  
Major Cluster ◽  
Peripheral Spondyloarthritis

: Interstitial lung disease (ILD) is the most common form of pulmonary impairment in patients with rheumatoid arthritis (RA). However, patients with RA or other arthritic diseases such as psoriatic arthritis (PsA) or peripheral spondyloarthritis (pSpA) may develop several other pulmonary diseases such as chronic obstructive lung disease (COPD) with a higher risk than patients without arthritis. The article at hand aims at summarizing the current knowledge on the prevalence of pulmonary diseases in the above-mentioned forms of arthritis, the challenges for prevalence studies and detecting pulmonary diseases in patients with arthritis as well as possible treatment options. Dyspnea, cough or other pulmonary symptoms or findings in arthritis patients should prompt gradual diagnostic procedures considering pulmonary manifestations as a major cluster of differential diagnosis. Considering its poor prognosis and morbidity burden, RA-ILD needs to be ruled out. Treatment of manifestations often lacks solid evidencebased guidelines and referrals to specialized centers are often necessary.

scholarly journals Diffuse leptomeningeal glioneuronal tumor with high-grade features masquerading as tubercular meningitis—a case report

2021 ◽  
Vol 52 (1) ◽  
Author(s):  
Sameer Peer ◽  
Vivek Murumkar ◽  
Karthik Kulanthaivelu ◽  
Chandrajit Prasad ◽  
Shilpa Rao ◽  
...  
Keyword(s):  
Case Report ◽  
Early Diagnosis ◽  
Histopathological Examination ◽  
Glioneuronal Tumor ◽  
Communicating Hydrocephalus ◽  
High Grade ◽  
Endemic Region ◽  
Tubercular Meningitis ◽  
Leptomeningeal Enhancement ◽  
Diffuse Leptomeningeal Glioneuronal Tumor

Abstract Background Diffuse leptomeningeal glioneuronal tumor (DLGNT) has been recently described in the literature. The complete neuroimaging spectrum and histopathological characteristics of this entity are yet to be elucidated. In an endemic region, diffuse leptomeningeal enhancement on neuroimaging with associated communicating hydrocephalus is usually suggestive of infective meningitis and the patients are started on empirical anti-microbial therapy. However, it is important to consider other differential diagnosis of leptomeningeal enhancement in such cases, particularly if the clinical condition does not improve on anti-microbial therapy. An early diagnosis of a neoplastic etiology may be of particular importance as the treatment regimens vary considerably depending on the underlying disease condition. Case presentation In this case report, we describe a case of DLGNT with high-grade histopathological features which was initially managed as tubercular meningitis based on the initial neuroimaging findings. Due to worsening of the clinical course and subsequent imaging findings at follow-up, a diagnosis of DLGNT was considered and subsequently proven to be DLGNT with features of anaplasia on histopathological examination of leptomeningeal biopsy specimen. Conclusion This case highlights the importance of recognizing certain subtle finding on MRI which may help in an early diagnosis of DLGNT which is crucial for appropriate treatment.

Planning for End of Life

2021 ◽  
pp. 104990912110141
Author(s):  
Natasha Ansari ◽  
Eric Johnson ◽  
Jennifer A. Sinnott ◽  
Sikandar Ansari
Keyword(s):  
End Of Life ◽  
Treatment Options ◽  
Stage Iv ◽  
P Value ◽  
Life Planning ◽  
Number Of Patients ◽  
End Of Life Planning ◽  
The Difference ◽  
Alternative Medications ◽  
Patient’S Perception

Background: Oncology provider discussions of treatment options, outcomes of treatment, and end of life planning are essential to care for patients with advanced malignancies. Studies have shown that despite this, many patients do not have adequate care planning, including end of life planning. It is thought that the accessibility of information outside of clinical encounters and individual factors and/or beliefs may influence the patient’s perception of disease. Aims: The objective of this study was to evaluate if patient understanding of treatment goals matched the provider and if there were areas of discrepancy. If a discrepancy was found, the survey inquired further into more specific aspects. Methods: A questionnaire-based survey was performed at a cancer hospital outpatient clinic. 100 consecutive and consenting patients who had stage IV non-curable lung, gastrointestinal (GI), or other cancer were included in the study. Patients must have had at least 2 visits with their oncologist. Results: 40 patients reported their disease might be curable and 60 reported their disease was not curable. Patients who reported their disease was not curable were more likely to be 65 years or older (P-value: 0.055). They were more likely to report that their doctor discussed the possibility of their cancer getting worse (78.3% VS 55%; P-value 0.024), that their doctor discussed end of life plans (58.3% VS 30%; P- value: 0.01), and that they had appointed a health care decision-maker (86.7% VS 62.5%; P-value: 0.01). 65% of patients who thought their disease might be curable reported that their doctor said it might be curable, compared with only 6.7% of patients who thought their disease was not curable (p < 0.001). Or, equivalently, 35% of patients who thought their disease might be curable reported that their doctor’s opinion was that it was not curable, compared with 93% of patients who thought their disease was not curable (p < 0.001). Patients who had lung cancer were more likely to believe their cancer was not curable than patients with gastrointestinal or other cancer, though the difference was not statistically significant (p = 0.165). Patients who said their disease might be curable selected as possible reasons that a miracle (50%) or alternative medicine (66.7%) would get rid of the cancer, or said their family wanted them to believe the cancer would go away (16.7%) or that another doctor said it would (4.2%). Patients who said their disease might be curable said they did so due to alternative medications, another doctor, or their family. Restricting to the 70 patients who reported their doctors telling them their disease was not curable, 20% of them still said that they personally felt their disease might be curable. Patients below 65 years of age were more likely to disagree with the doctor in this case (P-value: 0.047). Conclusion: This survey of patients diagnosed with stage IV cancer shows that a significant number of patients had misunderstandings of the treatment and curability of their disease. Findings suggest that a notable proportion kept these beliefs even after being told by treating physicians that their disease is not curable.

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