A frequent radiographic feature of dactylitis is enhanced signal at digital entheses without accompanying synovitis or tenosynovitis. At the histologic level, hypervascular tenosynovium with a fibromyxoid expansion of fibrous tissue can be seen, and perivascular inflammation with a T cell predominance, specifically CD3+ T cells, can occur.4
TNF inhibitor-induced autoimmune hepatitis was a concern for this patient. While discussing the literature on this topic, Dr. Orbai noted this complication is more common in patients treated with etanercept, adalimumab and infliximab than in patients treated with golimumab or certolizumab. TNF inhibitor-induced autoimmune hepatitis is more common in women than in men, and when detected, the treatment approach is to discontinue the TNF inhibitor, follow liver function tests and immunoglobulins, and potentially consider corticosteroids and/or azathioprine if the disease warrants such treatments.5
Dual-Biologic Therapy
In the third patient story presented by Dr. Orbai, the concept of dual-biologic therapy was explored. This patient was a 45-year-old business owner with refractory PsA who was having breakthrough signs and symptoms of active disease despite treatment with guselkumab every eight weeks. Thus, using a shared decision-making model with the patient, certolizumab was added at weeks 4 and 6, between guselkumab doses.
Dr. Orbai pointed out that dual-biologic therapy is an off-label treatment and is not officially approved by the U.S. Food & Drug Administration. However, emerging literature describes dual therapy in the care of patients with psoriasis and PsA.6,7
In one report from this past year, Haberman et al. described the first reported case of severe PsA remission (without the appearance of an adverse event) in a biologic-naive patient using a dual anti-cytokine regimen. To justify this strategy, the authors explained that, “given the complex and heterogeneous nature of tissue involvement in [psoriatic arthritis], it seems biologically implausible that modulating individual pathways will suffice for the induction of deep, enduring clinical responses in all phenotypic domains [i.e., skin, synovium, entheses and axial].”6
In her presentation, Dr. Orbai noted that such dual-therapy strategies warrant further rigorous evaluation in clinical studies.
In Sum
To conclude her talk, Dr. Orbai left the audience with several take-home messages. First, she noted that psoriasis and PsA are on a continuum, and it is important to evaluate the various domains of disease for patients, such as synovitis, enthesitis, dactylitis, skin and nail disease.
Second, no diagnostic test exists for PsA, and diagnosis depends on the combination of historical, physical exam, lab and imaging features consistent with this disease.
