Anne D. Martens, RN

Early diagnosis is the key to successful management of psoriatic arthritis, and treatment of this inflammatory disease is largely dependent on which symptoms are predominant.

Although professional golfer Phil Mickelson’s diagnosis of psoriatic arthritis (PsA) in 2010 may be the event that spurred widespread awarness of the disease, he joined an estimated 520,000 people in the United States impacted by PsA.

PsA is an immune-mediated disease in which the immune system attacks the skin and joints. PsA can develop slowly with mild symptoms or it can occur with a rapid and severe onset. Early recognition, diagnosis, and treatment of PsA are imperative to help limit structural joint damage that can occur with the disease.

It is not known exactly what triggers the immunological response, but it can result from an infection, such as strep throat, that activates the immune system. There is also evidence to suggest a hereditary component, with approximately 40% of PsA patients reporting a family member with psoriasis or arthritis.

In approximately 85% of PsA patients, the skin manifestations of psoriasis such as red, scaly patches precede joint involvement. It is imperative that patients with plaques communicate with their health care providers if they develop any joint pain. Although estimates vary widely, it is thought that up to 30% of patients with psoriasis develop PsA. However, PsA can also present in patients without skin lesions, especially in those patients who have relatives with plaque psoriasis. The onset of PsA usually occurs between the ages of 30 to 50 years, with an equal prevalence among males and females.

PsA typically presents with 1 or more symptoms such as fatigue; pain or swelling over tendons; swollen fingers and toes; stiffness, pain, swelling, and tenderness in 1 or more joints; a reduced range of motion; morning stiffness and tiredness; toenail or fingernail changes that may mimic a fungal infection; and redness or pain of the eye. PsA may also develop in a joint after an injury and can have much of the same symptomatology of a cartilage tear. Although PsA often affects the distal joins in appendages, the lower back, wrist, knees, and ankles may also be impacted.

Diagnosis of PsA is made on a clinical basis and often follows the “classification criteria for psoriatic arthritis” (CASPAR). To be classified as having PsA, a patient must meet 3 or more of the following criteria: evidence of psoriasis including current psoriasis, personal history of psoriasis, or family history of psoriasis; psoriatic nail dystrophy; negative test for rheumatoid factor; current or past history of dactylitis (swelling of an entire digit); or radiological evidence of juxta-articular new bone formation.

PsA must be distinguished from other conditions such as rheumatoid arthritis (RA) and gout. RA generally involves joints symmetrically on both sides of the body and rheumatoid factor is normally present in RA patients where it is not typically found in those patients impacted by PsA. However, it is possible but rare to have a patient concomitantly diagnosed with PsA and RA. Patients can also be misdiagnosed with gout, particularly if their PsA symptoms present in the big toe. In addition, uric acid levels can be elevated in PsA patients due to skin cell turnover or an aspirin regimen.

There are 5 types of PsA: symmetric PsA, asymmetric PsA, distal interphalangeal predominant, spondylitis, and arthritis mutilans (Table 1).

Treatment of PsA is largely dependent on predominant symptoms and most likely involves both a dermatologist and a rheumatologist.

The skin symptoms related to psoriasis are often treated with topical medications. These topical products include topical corticosteroids to reduce inflammation and swelling along with antrhalin, synthetic vitamin D3, vitamin A, salicylic acid, and coal tar. Additional topical treatments may center on moisturizing, soothing, reducing scaling, and relieving itching and include aloe vera, jojoba, zinc pyrithione, and capsaicin. Phototherapy can also be used to treat the skin lesions that may be present with PsA. Ultraviolet light B (UVB), ultraviolet light A (UVA), psoralen plus UVA (PUVA), and laser treatments have all been used as part of a phototherapy regimen to treat psoriasis.

Initial treatment of the arthritis component of PsA is centered on reducing the pain and inflammation. Nonsteroidal anti-inflammatories that block both cyclooxygenase-1 and cyclooxygenase-2 (COX-1 and COX-2) such as ibuprofen, naproxen, aspirin, and nabumetone are often used to reduce joint pain and inflammation. COX-2 inhibitors that are selective for the action of COX-2, such as celecoxib, can also be used.

If the arthritis and psoriasis symptoms don’t respond to the initial treatments, disease modifying anti-rheumetic drugs (DMARDs) and immunosuppressants may be used. These include sulfasalazine, methotrexate, cyclosporine, leflunomide, and azathioprine. Although labeled DMARDs, these drugs do have an impact on the autoimmune etiology of the psoriasis component as well.

In addition to the DMARDs, there are biologic options for the treatment of PsA. Adalimumab (Humira; Abbott), etanercept (Enbrel; Amgen), golimumab (Simponi; Janssen), infliximab (Remicade; Janssen), certolizumab (Cimzia; UCB), and ustekinumab (Stelara; Janssen) all carry the FDA’s indication to treat PsA. These biologic drugs work to decrease the symptomatology of both the psoriatic component as well as the arthritic component and may prevent joint deterioration.

Adalimumab, etanercept, golimumab, infliximab, and certolizumab are inhibitors of tumor necrosis factor-α (TNF-α). This action downregulates the signals that cause inflammation and interrupt the inflammatory cycle present in PsA. The anti-TNF agents carry a boxed warning indicating the importance of avoiding anti TNF-α agents if patients have an active serious infection or develop one during treatment. Test patients for latent tuberculosis prior to starting treatment and monitor for active tuberculosis during treatment.

There is a boxed warning indicating that lymphoma and other malignancies can occur in patients being treated with TNF blockers, so it is important to monitor patients for any signs of malignancy. It is also important to monitor for worsening or new onset heart failure when a patient is using a TNF blocker and anaphylaxis or serious allergic reactions can occur. Furthermore, exacerbations or new onset of demyelinating disease is possible, so patients with a history of multiple sclerosis should avoid TNF blockers. Patients who are hepatitis B virus (HBV) carriers should be monitored during and for several months after therapy for potential HBV reactivation. The most common adverse events with these agents are infections, injection site reactions (adalimumab and etanercept) or infusion reactions (infliximab), headache, and rash.

Ustekinumab is an interleukin(IL)-12 and an IL-23 antagonist. IL-12 and IL-23 are cytokines that are involved in inflammatory and immune responses, such as natural killer cell activation and CD4+ T-cell proliferation. By disrupting this signaling pathway, the inflammatory cycle present in PsA may be reduced. Although not called out by the FDA as a boxed warning in the prescribing information, it is still important to monitor for signs and symptoms of infection or malignancies and to perform a test for latent tuberculosis prior to starting treatment and to monitor all patients for active tuberculosis during treatment.

Anaphylaxis and other hypersensitivity reactions can occur and it is important to monitor for the possibility of reversible posterior leukoencephalopathy syndrome (RPLS) as there was 1 case reported. RPLS is a neurological disorder not caused by demyelination or a known infection. It presents with headache, seizures, confusion, and visual disturbances. Similarly to the anti-TNF agents, common adverse reactions consist of increased risk of infections, headache, and fatigue.

The above information is a selective summary of publicly available information and is accurate as of the date of writing. Please consult the sources for complete reference information. The views expressed in this article are those of the author alone and not of Managed Health Care Associates, Inc, or Diamoto Specialty Pharmacy Inc. 

		1. Vandlever LA. Psoriatic arthritis: Phil Mickelson’s story. Healthline. January 2014. www.healthline.com/health-slideshow/phil-mickelson-arthritis. Accessed July 1, 2014.

		Gelfand JM, Gladman DD, Mease PJ, et al. Epidemiology of psoriatic arthritis in the population. J Am Acad Dermatol. 2005;53(4):573. www.ncbi.nlm.nih.gov/pubmed/16198775. Accessed July 1, 2014.

		Diagnosing psoriatic arthritis. National Psoriasis Foundation. www.psoriasis.org/psoriatic-arthritis/diagnosis. Accessed July 1, 2014.

		Psoriatic arthritis. American College of Rheumatology. www.rheumatology.org/Practice/Clinical/Patients/Diseases_And_Conditions/Psoriatic_Arthritis/. Accessed July 1, 2014.

		Philipose J. Classification criteria for psoriatic arthritis: CASPAR. Rheumatology Network website. June 14, 2012. www.rheumatologynetwork.com/psoriatic-arthritis/classification-criteria-psoriatic-arthritis-caspar. Accessed July 1, 2014.

		Psoriatic arthritis health center. Web MD. August 2012. www.webmd.com/arthritis/psoriatic-arthritis/psoriatic-arthritis. Accessed July 1, 2014.

		Psoriasis treatments. National Psoriasis Foundation. www.psoriasis.org/about-psoriasis/treatments. Accessed July 1, 2014.

		Humira [prescribing information]. North Chicago, IL: Abbvie; May 2014. www.rxabbvie.com/pdf/humira.pdf. Accessed July 1, 2014.

		Enbrel [prescribing Information]. Thousand Oaks, CA: Amgen; November 2013. http://pi.amgen.com/united_states/enbrel/derm/enbrel_pi.pdf. Accessed July 1, 2014.

		Remicade [prescribing information]. Horsham, PA: Janssen Biotech, Inc; November 2013. www.remicade.com/shared/product/remicade/prescribing-information.pdf. Accessed July 1, 2014.

		Simponi [prescribing information]. Horsham, PA: Janssen Biotech, Inc; January 2014. www.simponi.com/shared/product/simponi/prescribing-information.pdf. Accessed July 1, 2014.

		Cimzia [prescribing information]. Smyrna, GA: UCB, Inc; October 2013. www.cimzia.com/pdf/Prescribing_Information.pdf.

		Stelara [prescribing information]. Horsham, PA: Janssen Biotech, Inc; March 2014. www.stelarainfo.mobi/hcp/files/prescribing_info.pdf. Accessed July 1, 2014.

Stacey Ness, PharmD, RPh, CSP, MSCS, AAHIVP

, has worked in both national specialty pharmacy and payer organizations and has experience in clinical management, adherence and persistency programs, as well as chronic disease cost optimization strategies. Dr. Ness is active in the Consortium of Multiple Sclerosis Centers, Academy of Managed Care Pharmacy, National Home Infusion Association, National Association of Specialty Pharmacy, Specialty Pharmacy Certification Board, and Hematology and Oncology Pharmacy Association, and has served on the Minnesota Medicaid Drug Formulary Committee since 2008. She is a multiple sclerosis certified specialist, a credentialed HIV pharmacist, a certified specialty pharmacist, and currently serves as the director of specialty clinical services at Managed Health Care Associates, Inc, a health care services organization based in Florham Park, New Jersey.

Articles

Psoriatric Arthritis: An Overview

Needle phobia can significantly affect the well-being of patients who are serviced by specialty pharmacies, but techniques can be employed to help mitigate its impact. 

We’ve all heard of arachnophobia (fear of spiders) and acrophobia (fear of heights), but what about trypanophobia? Trypanophobia is defined as extreme fear of medical procedures involving injections or needles. Although sometimes also referred to as aichmophobia, belonephobia, or enetophobia, those terms generally denote a fear of pins, needles, or sharp objects while tryphanophobia also includes the medical aspect of the fear. However, trypanophobia is commonly referred to as needle phobia.

This can and does impact many people significantly, particularly those patients serviced by specialty pharmacies. Fear of needles can prevent people from seeking out medical care, visiting the dentist, following prescribed treatments, and obtaining necessary lab work. As health care providers working with injectable and infused products, awareness of trypanophobia as well as knowledge of mitigation strategies is important when helping patients.

Trypanophobia was officially recognized in the American Psychiatric Association 

Diagnostics and Statistical Manual of Mental Health Disorders, 4th Edition (DSM-IV)

 in 1994 as a specific phobia of blood-injection-injury type.

 Because it was relatively recently defined and this population of patients may self-select out of the health care system, its prevalence is difficult to define. In a Canadian community study of 449 women, it was found that 21.2% experienced mild to intense fear and 4.9% had a phobic level of fear of injections, physicians, dentists, and hospitals. In another study, 11% of British medical office patients reported the dread of a painful injection. Yet another study reported that 23% of Swedish and 27% of American college students cite needle phobia as the main reason for not donating blood.

Several studies have also attempted to assess the associated demographics of patients who suffer from needle phobia. These studies tended to show that needle-phobic patients were more likely to be women and of a younger age than those who did not exhibit signs of needle phobia. Hereditary predisposition has also been studied, with numerous studies showing that patients with a needle phobia tend to have biological relatives who also exhibited needle phobia at a much higher rate than what is seen for patients treated with other types of phobias. One possible theory for this phenomenon centers on the presence of a genetic trait that may have evolved in humans in response to avoidance to piercing, stabbing, and cutting injuries that may have been caused by teeth, claws, fangs, and sticks.

In addition to genetic factors associated with needle phobia, there is also a strong learned component to it as well. A study by Ost attempted to quantify the ways in which blood- and injection-phobic patients had acquired their phobia. It was found that a majority of patients (52%) associated the onset of their phobia to a conditioning experience; 24% due to a vicarious experience (such as seeing a sibling cry upon administration of an injection); 7% as a result of being given instruction or information; and 17% could not remember specific onset circumstances.

Current working hypotheses propose that needle phobia depends on both an inherited reflex that is hardwired in neurovascular and neuroendocrine pathways and on the learning of a conscious fear.

Typically, trypanophobic patients will present with physical symptoms such as syncope, near syncope, light-headedness, vertigo, diaphoresis, and nausea. It is proposed that the vasovagal reflex involved in the physiology of needle phobia may be a biphasic response. The initial phase, which may not be experienced by all people with trypanophobia, is a period of anticipatory increased heart rate and blood pressure prior to the needle puncture. This is followed by a sudden decrease in both heart rate and blood pressure after the needle puncture. The onset of the vasovagal response is usually rapid but short-lived. Blood pressure typically returns to normal after 2 hours and most patients feel well enough to return to normal activity after several hours.

However, there have been reported cases of loss of consciousness for several hours and some patients who report anxiety, malaise, and weakness for up to 2 days after the episode. Severe vasovagal syncope could also exacerbate underlying cardiovascular issues. In addition, patients who experience a vasovagal reaction are more likely to have intense fear during subsequent needle encounters.

 A trypanophobic reaction differs from the physical response to other types of fears, such as fear of spiders or heights, where anxiety, difficulty breathing, and racing heartbeat can occur but are not typically accompanied by a drop in blood pressure or fainting.

Trypanophobia impacts the physical and social well-being of those who suffer from it. Patients with needle phobias tend to avoid health care and the health care system for as long as possible. Fear of blood testing or immunizations can interfere with school, employment, or travel opportunities. Required blood tests for marriage licenses and prenatal care may impact personal decisions in patients with needle phobia as well. There have even been case reports of legal problems arising for patients when blood tests are court ordered and patients have refused to comply.

Once a phobia is identified and recognized, a number of techniques can be employed to help mitigate the fear that goes along with injection administration. Exhibiting compassion, understanding, and respect for the phobia and the patient are important components of any mitigation strategy. Patients should be offered education and reassurance and, depending on the severity of the phobia, counseled regarding the various options to counteract it. A specialty pharmacist, in conjunction with the patient’s physician, nurse, and other health care team members, may try one or more of the methods described in the next section to help patients cope with a needle phobia.

		Have the patient lie flat or tilt the chair so the patient’s legs are above his or her head when receiving an injection or a needle stick. This may assist in bringing more blood to the brain if the patient’s blood pressure begins to drop and may help prevent syncope.

		Utilization of a topical product to numb the injection site may benefit patients, particularly those who are extremely sensitive to pain. There are lidocaine gels and creams, available under a variety of different brand names, specifically indicated for this purpose. Since pain tends to be part of the reason for fear of injections, reducing that pain may reduce anxiety and avoid triggering the vasovagal reflex. Some of these products may also be available over the counter. It is important to discuss with the patient the time it can take for the preparation to induce enough dermal anesthesia to work, with recommended application occurring 60 to 90 minutes prior to the needle stick.

		Use the body’s own nervous system to divert attention from the injection. The gate control theory of pain hypothesizes that the final common pathway for sharp pain to the brain can be shut down by the nerves that transmit cold and vibration sensation. There are devices available on the market, such as the Buzzy, that transmit cold and vibration sensations between the injection site and the central nervous system. This pain misdirection has been shown to reduce pain in both children and adults.

		Desensitization therapy conducted by a clinician specializing in this type of patient management may help patients decondition the autonomic response patients can experience. Desensitization through controlled exposures to the stimulus requires a motivated patient, but is the most commonly employed technique. It is particularly helpful for those patients whose life is endangered by the avoidance of medical intervention.

		Other cognitive or behavioral approaches to trypanophobia are available as well. Professional guidance and support for patients with needle phobia can include helping a patient face their fear gradually, teaching relaxation techniques, teaching how to challenge negative thoughts that come along with fear, and other coping mechanisms.

		Hypnotherapy may be beneficial in certain patients with needle phobia and has been evaluated by several studies involving dental visits.

		Anxiolytics such as benzodiazepines and sedative hypnotics such as zolpidem have been used as a pharmacologic approach.

All of these strategies have 1 thing in common—an open dialogue between the patient and the health care team, so the patient can be empowered in his or her quest to overcome needle phobia and have the best opportunity for a positive therapeutic outcome. 

The above information is a selective summary of publicly available information and is accurate as of the date of writing. Please consult the sources for complete reference information. The views expressed in this article are those of the authors alone and not of Managed Health Care Associates, Inc, or Diamoto Specialty Pharmacy Inc.

		Trypanophobia. The Medical Dictionary. http://the-medical-dictionary.com/trypanophobia.htm#continue. Accessed March 4, 2014.

		Sokolowski CJ, Giovannitti JA Jr, Boynes SG. Needle phobia: etiology, adverse consequences, and patient management. 

		Ost LG. Acquisition of blood and injection phobia and anxiety response patterns in clinical patients. 

		Wright S, Yelland M, Heathcote K, Ng SK. Fear of needles: nature and prevalence in general practice. 

. 2009;38(3):172-176. http://macha.itc.griffith.edu.au/dspace/bitstream/handle/10072/27947/55983_1.pdf?sequence=1. Accessed January 29, 2014.

		Smith M, Segal R, Segal J. Phobias and fears: symptoms, treatment, and self-help for phobias and fears. www.helpguide.org/mental/phobia_symptoms_types_treatment.htm. Published December 2013. Accessed January 29, 2014.

		Needle phobia facts. Healthline; 2012. www.healthline.com/health/big-shots-trypanophobia-facts. Accessed January 29, 2014.

		Hamilton JG. Needle phobia: a neglected diagnosis. 

. 1995;41(2):169-175. http://web.archive.org/web/20080705023159/http://www.needlephobia.info/pages/Hamilton-Needlephobia.pdf. Accessed January 29, 2014.

		Dialysis needle fear: easing the sting. Medical Education Instititute; 2005. www.fistulafirst.org/LinkClick.aspx?fileticket=p88GAcZU2M0%3D&tabid=103. Accessed January 29, 2014.

		Gate control theory. Buzzy Drug Free Pain Relief, 2014. http://buzzy4shots.com/gate-theory/. Accessed January 29, 2014.

		Patient/family education: anesthetic cream (EMLA, LMX4). Children’s Hospital of Minnesota; August 2009. www.childrensmn.org/Manuals/PFS/Med/018866.pdf. Accessed January 29, 2014.

Stacey Ness, PharmD, RPh, CSP, MSCS, AAHIVP,

 has worked in both national specialty pharmacy and payer organizations and has experience in clinical management, adherence and persistency programs, as well as chronic disease cost optimization strategies. Dr. Ness is active in the Consortium of Multiple Sclerosis Centers, Academy of Managed Care Pharmacy, National Home Infusion Association, National Association of Specialty Pharmacy, Specialty Pharmacy Certification Board, and Hematology and Oncology Pharmacy Association, and has served on the Minnesota Medicaid Drug Formulary Committee since 2008. She is a multiple sclerosis certified specialist, a credentialed HIV pharmacist, a certified specialty pharmacist, and currently serves as the director of specialty clinical services at Managed Health Care Associates, Inc, a health care services organization based in Florham Park, New Jersey. 

has worked for over 35 years as a registered nurse in numerous settings, both in hospital and home care. Anne has devoted over 30 years of her professional career to the care of patients receiving infusion therapy as an intravenous (IV) nurse and IV team supervisor in the hospital, and the past 20-plus years caring for patients at home receiving IV therapy. Anne is an active member of the Infusion Nurses Society and the Immunoglobulin Nurses Society (IgNS), both organizations dedicated to the promotion of quality standards of patient care for patients receiving infusion therapy. She is currently on the credentialing exam committee for IgNS. Anne’s current role is director of Diamoto Medical Specialty Pharmacy. Previously she held the roles of national director of nursing at Bioscrip and national sales director for American Outcomes Management.

Needle phobia can significantly affect the well-being of patients who are serviced by specialty pharmacies, but techniques can be employed to help mitigate its impact.