What Do These Patient Symptoms Mean?

1. A 43-year-old man with psoriasis has pain and morning stiffness of the fingers. Which of the following medications reduces the progression of psoriatic arthritis?

A. Ustekinumab (Stelara)
B. Methotrexate
C. Leflunomide
D. Photochemotherapy with psoralen–UV-A (PUVA)

2. A 49-year-old man with no past medical history presents with psoriasiform plaques on the extensor aspect of the elbows and knees bilaterally, as well as in the gluteal cleft. He has no additional complaints. This patient may benefit from which of the following laboratory tests?

A. Echocardiography
B. Fasting glucose
C. Hemoglobin A_1C
D. Electrocardiogram 

Answer: A—Ustekinumab

In treating psoriatic arthritis, the choice of therapy is dependent on multiple factors, such as patient goals, preferences, severity of illness, and comorbidities. Patients with mild disease may benefit from treatment with nonsteroidal anti-inflammatory drugs, whereas patients with moderate to severe arthritis would be more likely to benefit from disease-modifying antirheumatic drugs, such as methotrexate and leflunomide. However, methotrexate and leflunomide have not been shown to reduce the radiologic joint damage of psoriatic arthritis, nor has PUVA.¹ Ustekinumab is an IL-12/IL-23 monoclonal antibody that has been shown to reduce the radiographic progression of psoriatic arthritis, although it is not FDA approved for prevention of joint progression.² Additional agents shown to prevent the radiographic progression of joint disease include tumor necrosis factor (TNF) inhibitors³ andanti-IL-17A monoclonal antibody.⁴

Answer: B—Fasting glucose

Metabolic syndrome is a disorder composed of obesity, diabetes mellitus, dyslipidemia, and hypertension; together these accelerate the risk of cardiovascular disease. In a review, metabolic syndrome was found in 31.4% of psoriasis patients (odds ratio, 1.42; 95% CI, 1.28-1.65).⁵ 

Psoriasis may serve as a cutaneous indication of underlying metabolic disease, and these patients may benefit from metabolic syndrome screening. Having psoriasis does not require specialized cardiovascular screening beyond what is recommended for patients based on their age and risk factors. However, age and risk factor-appropriate screening should be done and includes fasting cholesterol profile, blood pressure, body mass index, waist circumference, and fasting glucose.^6,7 Fasting glucose is the only answer included in the National Cholesterol Education Program Adult Treatment Panel-III guidelines.

Mr Visconti is a medical student and research associate at the Center for Dermatology Research at Wake Forest School of Medicine in Winston-Salem, NC.

Mr Bashyam is a medical student and research fellow at the Center for Dermatology Research at Wake Forest School of Medicine.

Dr Feldman is with the Center for Dermatology Research and the departments of dermatology, pathology, and public health at Wake Forest School of Medicine.

Disclosures: Mr Visconti and Mr Bashyam report no relevant financial relationships. Dr Feldman has received research, speaking and/or consulting support from a variety of companies including Galderma, GSK/Stiefel, Almirall, Leo Pharma, Boehringer Ingelheim, Mylan, Celgene, Pfizer, Valeant, Abbvie, Samsung, Janssen, Lilly, Menlo, Merck, Novartis, Regeneron, Sanofi, Novan, Qurient, National Biological Corporation, Caremark, Advance Medical, Sun Pharma, Suncare Research, Informa, UpToDate and National Psoriasis Foundation. He is founder and majority owner of www.DrScore.com and founder and part owner of Causa Research, a company dedicated to enhancing patients’ adherence to treatment.