Background Psoriatic Arthritis (PsA) is a complex condition involving both axial and peripheral joints, together with enthesitis, dactylitis and skin. A complete assessment of PsA is challenging within the short time available in routine clinics. Assessment of these components is important as they all contribute significantly to disease burden, and may require specific treatments for optimal outcome.
Objectives As part of an initiative programme promoting the “Treat-to-Target” concept, a group of rheumatologists, dermatologists and nurse specialists considered ways of assessing all components of psoriatic disease in routine clinics. A modular approach for assessing psoriatic disease was proposed, with skin and axial disease initially assessed by questionnaire. Patients identified with significant symptoms could then be further clinically assessed. This study reports patient acceptability and utility of this proposal in a routine clinic setting.
Methods A trained receptionist handed two questionnaires to sequential patients with psoriatic arthritis attending routine clinics at Guy’s Hospital, asking two questions:Questionnaire 1: Have you been suffering from any neck or back pain recently? Questionnaire 2: Do you have psoriasis at the moment?
If patients answered yes to question 1, the questionnaire invited them to complete the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), on the reverse side. If they answered yes to question 2, they completed the Dermatology Life Quality Index (DLQI). Questionnaires had a tick-box format, and were completed in the waiting area prior to their appointment, then reviewed at their consultation with the doctor. Patients who had BASDAI scores >4 were seen again in a follow-up consultation at 3 months.
Results 70 pairs of questionnaires were distributed and completed. All patients found them easy to understand and to answer. 47 patients (67.1%) identified co-existing neck or back pain, with 28 (59.6%) scoring BASDAI >4. On further review, 19 had axial pain due to degenerative spinal disease, and 9 cases had active spondylitis. 45 patients (62.6%) identified themselves as having co-existing psoriasis, with 24 patients (51%) scoring DLQI >5 and 8 patients (17%) a DLQI >10.
Conclusions This preliminary use of screening questionnaires to facilitate a modular approach to the assessment of PsA showed high patient acceptability, and clinicians found the scores useful to indicate the extent of skin and axial involvement. We closely monitored our cohort with active spondylitis, and initially optimized NSAID therapy if possible. At three month follow up, 2 patients had repeat BASDAI >4, making them eligible for tumour necrosis factor inhibitor therapy. This was started in these 2 patients with good effect. DLQI >5 indicates significant skin involvement. 62.6% of our patient group reported skin involvement, of whom over a third had a DLQI >5, but only 8 of 70 patients had a score >10 suggesting more severe psoriasis activity.
We propose the use of these questionnaires in routine practice. This patient acceptable approach helps identify skin and axial skeleton involvement early, so that treatment can be optimized quickly. In the future this approach will assist new composite disease activity measures for the assessment and treatment of psoriatic arthritis.
Acknowledgements Abbott Immunology supported the Psoriatic Arthritis Assessment Academy programme.
Disclosure of Interest None Declared