Training on the Modular Approach on the assessment and management of psoriatic arthritis (PsA) for dermatology units This PsA Assessment initiative is led by the UK PsA Assessment Academy for UK healthcare professionals only, organised and funded by AbbVie. Available to download at: www.psoriatic-arthritis.co.uk. Prescribing information can be found here or on the website: https://www.psoriatic-arthritis.co.uk/healthcare-professionals-psa.aspx. AXHUR151220n(1) Date of preparation: December 2017

Overview of PsA

What is PsA? Psoriatic arthritis (PsA) is a progressive disorder ranging from mild synovitis to severe progressive erosive arthropathy1 PsA is a complex condition that involves many body areas: Skin Fingernails and toenails Peripheral joints Axial skeleton (the spine, chest and sacroiliac joint) Entire digits (dactylitis) Entheses 1. Pipitone N, et al. Rheumatol 2003; 42:1138–1148.

1. NICE Technology appraisals.TA199, August 2010. Prevalence of PsA The prevalence of psoriasis in the general population is estimated at 2–3%, with the prevalence of inflammatory arthritis in people with psoriasis estimated at up to 30%1 At least 20% of people with psoriasis have severe psoriatic arthritis with progressive joint lesions1 1. NICE Technology appraisals.TA199, August 2010.

Diagnosis Many patients with PsA remain undiagnosed: In a study looking at PsA prevalence in Europe and North America of 285 patients given the diagnosis of PsA by a rheumatologist, 117 (41%) had not been previously given the diagnosis 1 PsA can progress notably within the first 2 years of disease onset2 Dual skin and joint involvement can have a negative impact on a patient’s quality of life3 It is, therefore, critical to diagnose and commence treatment early 1. Mease P, Gladman D, Papp K, et al. J Am Acad Dermatol. 2013;69(5):729–735. 2. Gladman DD, et al. Ann Rheum Dis. 2005; 64 :14–17. 3. Lee S, et al. P & T 2010; 35:680-689.

Diagnosis Patients may present to either a dermatology or rheumatology clinic depending on their symptoms To optimise best practice all patients with psoriasis should be screened for PsA to help prevent irreversible joint damage

PsA Assessment Academy Outside In recommendations are based on the expert opinion of the PsA Assessment Academy

Objectives of training To provide background information on PsA To explain the new Modular Approach on the assessment of PsA To ensure all practitioners are proficient in using the assessment tools To agree a standardised assessment protocol for each clinic

PsA Assessment Academy A group of physician and nurse experts in rheumatology and dermatology were bought together by AbbVie to discuss the assessment of PsA based on the available evidence: Bruce Kirkham, Consultant Rheumatologist, Guy’s Hospital, London Philip Helliwell, Consultant Rheumatologist/Senior Lecturer, Leeds University Eleanor Korendowych, Consultant Rheumatologist, Royal National Hospital for Rheumatic Diseases, Bath Kate Gadsby, Rheumatology Consultant Nurse, AbbVie & Honorary Rheumatology Nurse Specialist, Royal Derby Hospital, Derbyshire* Sue Oliver, Past Chair RCN Rheumatology Forum and RCN Fellow. Independent Nurse Consultant Liz Parrish, Past Dermatology Lead Nurse/Matron, East Kent University Hospitals NHS Foundation Trust. Independent Nurse Consultant * Kate Gadsby works predominantly with AbbVie Ltd. But, also has a role within the NHS as an honorary rheumatology nurse specialist at Derby Hospital

Academy recommendations Practical recommendations were put forward that could: Optimise initial assessment and monitoring of PsA by recommending a standardised approach to assessment Improve coordination between rheumatology and dermatology services

Aligning with existing guidelines The recommendations were developed to build on and align with existing guidelines issued by the: British Society of Rheumatology (BSR) Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) National Institute for Clinical Excellence (NICE) Scottish Intercollegiate Guidelines Network (SIGN)

A Modular Approach

A Modular Approach Developed by the Assessment Academy, a Modular Approach was recommended which encourages sharing of knowledge and information, efficient use of time, and prompt referral and treatment of patients. As part of this approach, it has been suggested that as a minimum: Dermatology clinics should perform the PASI and the PEST. Over time the other components of the Modular Approach can be added to clinic practice

Applying the Modular Approach to daily clinical practice Agree a standardised approach for each test in your clinic All patients should be assessed for PsA Recommended assessment tools include: Dermatology Life Quality Index (DLQI) Psoriasis Area and Severity Index (PASI) Psoriasis Epidemiology Screening Tool (PEST)

Clinical questionnaires

Clinical questionnaires Clinical questionnaires can be useful for the continued management of patients who have PsA A trained receptionist or nurse can give the patient the questionnaire when the patient first arrives Clinical questionnaires should be completed periodically by the patient, or as required

Dermatology Life Quality Index (DLQI) The DLQI is a quality of life (QoL) measure that can be used across all skin diseases and measures different aspects of psoriasis to the PASI The DLQI consists of 10 simple questions relating to ways in which skin disease impairs lives The DLQI is calculated by summing the score of each question with a maximum of 30. The higher the score, the more quality of life is impaired

Dermatology Life Quality Index (DLQI) Healthcare professional pages Patient pages All Outside In materials can be downloaded from www.psoriatic-arthritis.co.uk/healthcare-professionals-psa.aspx

Assessing the skin

Psoriasis Area Severity Index (PASI) PASI is an index used to express the severity of psoriasis considering the following: severity (erythema, induration and desquamation) percentage of affected area The body is assessed in four regions: Head and neck Arms Trunk (includes groin and axillae) Legs (includes buttocks) All Outside In materials can be downloaded from www.psoriatic-arthritis.co.uk/healthcare-professionals-psa.aspx

Psoriasis Area Severity Index (PASI) Each is assigned a score to reflect extent of affected area, (0 = no skin affected, 6 = all skin affected) Severity of psoriasis is assessed with scores assigned to each of redness, thickness and scale (0= least severe, 4 = most severe) For head, arms, trunk and legs specify: The percentage of area of skin involved The severity of three clinical signs (erythema, induration and desquamation) on a scale from 0 to 4 (from none to maximum)

Psoriasis Area Severity Index (PASI) The PASI is the main test used in the clinic to assess total body area affected by psoriasis It can be used to monitor both the patient’s psoriasis and their disease progression and response to treatment over time The test can be used to help decide the most appropriate treatment

Psoriasis Area Severity Index (PASI) Nails should be visually assessed for pitting during examination

Psoriasis Area Severity Index (PASI) All Outside In materials can be downloaded from www.psoriatic-arthritis.co.uk/healthcare-professionals-psa.aspx

PASI score calculation Area affected was estimated to be 35% which gives an extent score 3 The total extent for the arms is 3 x 0.2 = 0.6 Severity of the plaques on the arms was calculated as 3 for erythema, 2 for scaling and induration as 2 The severity for the arms was calculated as 3+2+2 = 7 The total extent multiplied by total severity for the arms is 0.6 x 7 = 4.2

PASI score calculation The calculation of the PASI for this patient is shown below:

Assessing the joints

Psoriasis Epidemiology Screening Tool (PEST) PEST should be considered for early detection of PsA Patients with psoriasis who have not been diagnosed with PsA should complete a PEST questionnaire annually Patients complete 5 questions scoring 1 point for each question answered in the affirmative All Outside In materials can be downloaded from www.psoriatic-arthritis.co.uk/healthcare-professionals-psa.aspx

Psoriasis Epidemiology Screening Tool (PEST) The patient is also asked to show on a diagram which joints have caused them discomfort (still, swollen or painful joints) A total score of 3 or more is indicative of psoriatic arthritis and patients should be referred for further assessment by a rheumatology unit All Outside In materials can be downloaded from www.psoriatic-arthritis.co.uk/healthcare-professionals-psa.aspx

Psoriasis Epidemiology Screening Tool (PEST) All Outside In materials can be downloaded from www.psoriatic-arthritis.co.uk/healthcare-professionals-psa.aspx

Training materials

Training materials A selection of training materials are available on the Outside In website: www.psoriatic-arthritis.co.uk/healthcare-professionals-psa.aspx

Summary Agree a standardised approach for each test in your clinic As a minimum, it has been suggested by the PsA Assessment Academy that: Dermatology clinics should perform the PASI and the PEST A total PEST score of 3 or more is indicative of psoriatic arthritis and patients should be referred for further assessment by a rheumatology unit All patients should be assessed for PsA PEST should be considered for early detection of PsA