Alexis Ogdie, MD, on Sex-Specific Differences Among Patients With Psoriatic Arthritis

Dr Ogdie reviews her recent research into how men and women experience psoriatic arthritis, including its effects on quality of life and physical functioning.

Alexis Ogdie, MD, is associate professor of medicine and epidemiology in the Perelman School of Medicine and director of the Center for Clinical Epidemiology and Biostatistics and director of the Penn Psoriatic Arthritis and Spondyloarthritis Program at the University of Pennsylvania in Philadelphia, Pennsylvania. 

Welcome to this podcast from the Rheumatology & Arthritis Learning Network. I'm your moderator, Rebecca Mashaw, and today I'm delighted to welcome back Dr. Alexis Ogdie, who's associate professor of medicine and of epidemiology at the hospital of the University of Pennsylvania. She's going to share some insights into her research into psoriatic arthritis, and specifically how men and women experience this disease in different ways. Thanks for coming back to talk with us again.

Alexis Ogdie:

Thanks so much for the opportunity.

RALN:

So what led you to choose this topic to do research on, in how men and women experience PsA differently?

Dr Ogdie:

Well, I think over the last several years there's been a number of abstracts and studies examining cross-sectional data and finding that women generally had poorer outcomes than men at any one given point in time. In addition, there were a couple of studies suggesting that women were not responding as well to therapy and were achieving low levels of disease activity or minimal disease activity with a lower prevalence than men.

So in this particular study, we wanted to summarize all the available data to get a bird's eye view of the different studies, and how they're kind of tracking together.

RALN:

And what did that show you?

Dr Ogdie:

So in this study, we examined a number of different papers. Mostly were cross-sectional, some were responsiveness—so how did patients change over time with therapy, for example. We looked at, were men responding better, women responding better, or were the two groups responding the same?

There's this nice figure in the paper that I would point you to, in which it kind of summarizes visually, and you can see red dots when women were worse than men and blue dots when men were worse than women and in gray. And what you see is a sea of red.

And so women in general across all of the different outcomes for the most part, didn't do as well across a large number of different cohorts. So I think this demonstrates that this isn't just a single cohort or a one-off abstract, but really a good amount of data suggesting that women really don't do as well as men with psoriatic arthritis and with treatment response.

RALN:

So this is a standing pattern that you're seeing in PsA, that women just are not doing as well as men, even with, I guess, comparable treatment?

Dr Ogdie:

Exactly. And there may be multiple reasons for this. And so this is primarily within patient reported outcomes that you see the biggest differences. When you look at swollen joints, you don't see as many differences. If you look at psoriasis body surface area for example, again, you don't see many differences there. So if we're looking at objective or physician-assessed outcomes, there's really less difference, and the greater differences are with those patient reported outcomes.

So maybe in how women report the outcomes, may be one piece, or how they interpret the outcomes, the social desirability for men not wanting to report bad outcomes. And then there probably is some biology to this as well, which needs to be further investigated.

RALN:

Were you surprised at all by these findings?

Dr Ogdie:

No, I think it's just a nice summary. And I guess I was surprised by the amount of red dots, I think I would've thought that there was a little more balance. But it was pretty skewed toward women really not doing as well.

RALN:

You did a study earlier this year that found that women with PsA reported a worse quality of life, greater levels of disability, and more work impairment than men, with equivalent disease duration and presentation. So between that research and this, did you find anything that would shed some light on why these differences exist? And you just pointed out a couple, maybe women experience it differently, maybe men are reluctant to report that they're not doing as well. What do you think might be at work here?

Dr Ogdie:

Yeah. So I think the results from that study were very consistent with this study and kind of fit nicely into this fold. Right now, Lihi Eder as a part of GRAPPA is leading a large study called the SAGE study to really understand this from a pathophysiology perspective, examining hormones and cycles and postmenopausal versus premenopausal women, how does that all affect it? I think those are all things that need to be investigated.

Right now we think that it is about the reporting. It's also about function. So we did a focus group at one point with some patients, and the women were talking about how they use their hands. So taking care of a baby, changing a diaper, making lunches, holding a pot, and those may be different than some of the activities that men may be needing to do, for example. And so the joints involved and the impact of that joint being involved may be different depending on your role and what you're doing on a day-to-day basis.

And then hormones probably do play a role. We just don't understand that role yet, so I think there's more to learn about the biology.

RALN:

That's very interesting. What would you advise the practicing rheumatologist in terms of applying these findings to their practice, to make sure that their patients are getting the best level of care and that they're getting the right information from the patient on how they're really doing in terms of function, pain, skin presentation of psoriasis? How can they apply this?

Dr Ogdie:

So Laura [Coates, coauthor] and I have been advocating for a long time to do... Treating the whole patient. So really considering all the ways in which a patient's life and the disease impact are affecting the patient beyond the disease. So not only prescribing a therapy, but thinking about is there anxiety and depression, which was more common in women, because that's going to impact response to therapy. So identifying the anxiety and depression and managing it or referring them for management. Women tend to report a lot more fatigue and higher pain levels. There are things that we can do for that to help with both of those. And then function, physical therapy.

So really assessing what is bothering the patient, what's impacting the patient, and addressing that. And that the kinds of interventions we give women may be different than the kinds of interventions that we give men.

RALN:

They respond differently to different medication therapies.

Dr Ogdie:

There's some thought about that because different clinical trials have found differences. So some trials have found that women respond worse than men, some trials have found that they're similar. But I think that's really a numbers game. There's just not as many patients in those trials as some of the larger cohort studies. And it'd just be maybe one off, so if we'd repeat it in a larger cohort, who knows? I think that's some of what will be investigated in the SAGE study as well.

RALN:

So my next question was about further research, and of course it sounds like the SAGE study is the major one. Can you tell us a little bit about that, what you're looking at? And when you expect to see some results?

Alexis Ogdie:

Yeah, so this just started enrolling. It's an international study led by Lihi Eder, and it is enrolling I think 30 countries or something. So it's a really large study that will get cultural differences, I think, as well as sex differences and gender differences, and explore all those different dimensions.

I think it'll be a couple of years before we have a lot out of that, at least until we get some baseline data. And then there will be treatment follow-up data from that too. I think this is a really well-designed, exciting study that I'll look forward to seeing the results from.

RALN:

And so will we, and I hope we'll have you back then to talk about what you're finding out. Any final thoughts for your colleagues in rheumatology about working with men and women who have PsA, and what they might want to take into consideration?

Dr Ogdie:

No, I think just back to the same concept of treating the whole patient, and thinking about how is the disease impacting the patient? And recognizing that may be different between men and women, but different from person to person.

RALN:

Okay. Thanks very much. It was great to talk with you, and we look forward to talking with you again soon.

Reference:

Coates LC, van der Horst-Bruinsma IE, Lubrano E, et al. Sex-specific differences in patients with psoriatic arthritis: a systematic review. J Rheumatol. 2023;50(4):488-496.  DOI: 10.3899/jrheum.220386