Prior to the introduction of biologic drugs in 1999, many patients with severe psoriatic arthritis had to adopt and contend with a mindset of inevitability. Unfortunately, any severe damage that may have occurred prior to 1999 was likely to be irreversible. For example, in 2006 when a set of X-rays of my hips and knees led an orthopedic surgeon to predict that I would eventually need both knees and both hips replaced, I became resigned to what I would be forced to endure in the coming years -- surgeries and then weeks of rehabilitation and recovery. There was great uncertainty as to the endgame of my overall physical condition and mobility This seemed like a lifelong sentence of disruption to my quality of life; the only question was the extent of damage and its ultimate impact on my abilities, both physical and mental.
At that time, while there were some drugs that could lessen the pain of damaged and deteriorating joints, it did not appear that the then-existing disease-treating drugs, so called disease-modifying anti-rheumatic drugs or “DMARDs,” could change the course of the disease, which could lead to degradation and deterioration of the joints. Arguably, for some patients, the DMARDs might slow down the damage to the joints and mitigate the impacts of psoriatic arthritis. However, there were many patients whose disease was not adequately managed by DMARDs and pain medication.
I recall attending my first national conference of the National Psoriasis Foundation (NPF) in the early 2000s. About 10% to 15% of the people in the room of various ages were using some type of assistive device, either a cane, a walker, or a wheelchair. Admittedly, the crowd may have had more psoriatic arthritis patients than those with only psoriasis, but the visual impact was significant. Listening to the speakers and the attendees (both patients and caregivers), there was an overall sense of hopelessness due to the seeming inevitability of the outcome of psoriatic arthritis -- joint destruction, pain, and potential impairment of mobility.
Several years later, I attended another NPF conference, and the number of assistive devices was reduced to perhaps 5 to 10 individuals, and they were all older patients. This did not seem to be a coincidence, so I asked the dermatologists and rheumatologists at the conference. They all seemed to agree that the introduction of biologic drugs at an early stage of the disease was transformative -- it was preventing damage and destruction of joints.
Over time, as the number of patients taking biologic drugs increased, and as new and different biologic drugs were introduced, I sense that the mindset of psoriasis and psoriatic arthritis patients has changed, from hopelessness to hopeful. The earliest biologics drugs -- the TNF inhibitors -- were proving successful, to my understanding, in treating 30% to 40% of psoriasis patients.
As a result of genetic studies based in part on the Human Genome Project, in the last 5 years, newer drugs that are treating IL-17 and IL-23 genetic triggers have been shown to be effective in 70% to 80% of psoriasis patients. In some patients, either the TNF inhibitors or the IL class of drugs have appeared to have caused a remission of the psoriasis.
In younger patients who have been diagnosed within 6 months of the onset of psoriatic arthritis and have been treated with biologic drugs shortly after the onset of the disease, the remission could well mean that these patients will never suffer significant damage or destruction to their joints. This is truly a wonderful and revolutionary outcome. Unfortunately, for older psoriatic arthritis patients (like myself), the joint damage that has occurred prior to the introduction of biologics is irreversible. However, even for these patients, there should be no further destruction, and there should be a mitigation of continuing damage to the joints.
Recently, both the American Academy of Dermatology and the American College of Rheumatology (both professional associations of these specialists) have adopted new guidelines for the treatment of psoriasis and psoriatic arthritis, respectively. In both instances, the mantra is: “Early diagnosis and early treatment.’”
According to data collected by the American Joint Replacement Registry, patients with rheumatoid-like arthritis (including psoriatic arthritis) are having 50% less knee and hip replacement surgeries in the years following the introduction of biologic drugs. The orthopedic surgeons also attribute this reduction to the biologic drugs.
We have entered an era of continuing hope for psoriatic arthritis patients. The next challenge is to ensure that the maximum number of psoriasis and psoriatic arthritis patients can access the biologic drugs.
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