John Tesser, MD: Let’s get into the management. What’s the best approach to deal with patients with this disease? I guess the first thing let’s point out is, what about comorbid conditions? Do they affect in some way which direction one might go in terms of treatment choices, or classes of medicines, if you will?

Jennifer Simpson, DNP: Yes, definitely, I think so.I have quite a few patients, actually more than I would think even with my other types of diseases, who have immunodeficiency. I think that’s definitely a comorbid condition that we’re not always thinking of. Certain medicines are going to put them at higher risk of infections, and we’re not necessarily going to want to modify or suppress their immune system more with certain medicines. We really have to be quite selective with what we put them on safely and work very closely with their immunologist as far as what we feel comfortable trying on this patient and then watching them very closely. Of course, we’re very concerned about cardiovascular complications and comorbidities with these patients as well.

John Tesser, MD: Talk a little bit about that. What are the cardiovascular manifestations and comorbidities that put these people at risk?

Jennifer Simpson, DNP: We’ll see higher levels of hypertension, of hypercholesterolemia, increased risk of heart attacks and cerebrovascular accidents that will come along with that. And often these patients are obese and may have diabetes as well, so really a triad of very high risk of having those types of complications. I think that comes back to, a very important thing for these patients to understand is how much lifestyle really plays a role in overall how healthy they’re going to be.

I think starting that conversation early with a patient after they’ve been diagnosed is so important, so they understand. I tell patients these 6 things quite often: don’t smoke, don’t excessively drink, get good sleep, eat healthy, exercise, and try to manage your stress as much as possible. And they’ll ask me, “What can I be doing with supplements, or what can I be doing at home?” And those are the 6 things I will tell them. “If you take care of yourself in this way, you’re going to lessen your risk of developing these comorbidities and complications quite a bit.” I think it’s a frank conversation that we have to have with them, so they really understand the risks if they’re not choosing to make those lifestyle decisions and changes.

John Tesser, MD: Nehad, do you want to add to that in terms of any more specific dietary or exercise recommendations?This is the nonpharmacological approach to caring for these people, right?

Nehad Soloman, MD: Correct. Ultimately, when you think about comorbid conditions and the approach, there are 3 buckets.There’s the nonpharmacologic treatment, then there’s the acute treatment for, “I’m in pain give me something now,” and then there’s the long-term management strategy. Depending on which you are talking about, and I think Jen did a great job underscoring the importance of talking about exercise, smoking cessation, good sleep, weight loss, and so on. But then a comorbid condition such as diabetes may limit our utilization of steroids in the acute treatment. If a patient has renal failure for whatever reason or renal compromise, you may not want to use NSAIDs [nonsteroidal anti-inflammatory drugs], and so now your hands are a bit tied. But then even more so, comorbid conditions such as, as I mentioned before, inflammatory bowel disease may limit your utilization of let’s say an IL-17 [interleukin-17] drug, or if they have a history of CHF [congestive heart failure] or COPD [chronic obstructive pulmonary disease], the next thing you know you’re not using TNFs [tumor necrosis factor inhibitors] or you’re shying away from abatacept, or Orencia.

Effectively knowing all of this when you’re going into the room on the second visit, third visit, whatever have you, is going to be key because when you’re employing that treatment management, you want to make sure that you’re not doing something to harm the patient. You want to try to find the most effective treatment without offsetting something else. It’s always critical to know what else is going on with the patient before choosing your weapon. As you know, the guidelines from the ACR [American College of Rheumatology], and I’m sure we’re going to get there, are so broad. They give you an opportunity to use whatever you want up front, but most of that is going to be somewhat directed by comorbid conditions that the patient may have before you can choose your tool.

John Tesser, MD: My patients frequently ask what kind of diet they should be doing. Keto [ketogenic] diets come up a lot, and they’re aimed at losing weight when they talk about that. But the best advice that I think I can give them is to steer toward the Mediterranean-style diet, for which there is ample evidence in the medical literature that it’s anti-inflammatory and can have some particular benefits on the systemic inflammatory diseases as a whole; it can be true for rheumatoid arthritis, psoriatic arthritis, etc. There can be some weight loss associated with that, which can be helpful. Of course, these people usually are overweight to obese. If you look at all of the clinical trials on all of the medicines that we use, if you take a look at the BMIs [body mass indexes], they are, on average, about 30. And a lot of these people are in the high 30s or even 40s. That will have some impact for sure about what kind of exercise they can do. They’re not going to be running. They are probably best not to be jumping off of things or out of things onto susceptible knees. At least having that discussion with them to help them know what kind of exercise may be helpful is certainly a good way to go.

This transcript has been edited for clarity.