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Why Can't I Achieve Remission in My Psoriatic Arthritis?



Question: "I have psoriatic arthritis and I've been on seven different biologics. Why can't I achieve remission?"


It's unfortunate and rare, but more common with psoriatic arthritis than with rheumatoid arthritis. Let's see, as rheumatologists, approach medications, and explore possible reasons why remission is not achieved.



Our Approach as Rheumatologists


When we diagnose inflammatory arthritis, our goal is full remission. This means no more pain, swelling, tender joints, or morning stiffness. We usually cycle through medications every three months. The first line of treatment often starts with methotrexate. While it's less effective for psoriatic arthritis, insurance often mandates trying it first. If after three months, remission isn't achieved, we move on to a biologic. This cycle continues, usually every three to four months.


Understanding Your Diagnosis


Given the variety of effective treatments available today, we aim for full remission. However, if remission isn't achieved despite multiple biologics, we must consider if we are treating the correct diagnosis. Psoriatic arthritis is diagnosed clinically, based on symptoms like morning stiffness, joint swelling, and the presence of psoriasis. Misdiagnosis can occur, and conditions like osteoarthritis or fibromyalgia might be mistaken for psoriatic arthritis.


1. Correct Diagnosis

Psoriatic arthritis is diagnosed based on clinical symptoms, as there is no specific blood test. If joint pain is worse at the end of the day and aggravated by joint use, it might be osteoarthritis, which doesn't respond to biologics. Ensuring the correct diagnosis is the first step.


2. Treating the Correct Condition

You might have multiple conditions, like psoriatic arthritis and fibromyalgia, where the latter won't respond to biologics. Fibromyalgia involves widespread muscle and skin pain and requires different treatment.


3. Variety of Biologics

It's crucial to evaluate if you've tried different types of biologics. For example, if you've tried several TNF inhibitors, they all function similarly. Exploring other mechanisms of action in biologics can sometimes make a difference.



Deeper Reflections


Beyond clinical considerations, it's vital to consider the mind-body connection. Chronic conditions can be deeply frustrating, often leading to anger and emotional distress. Exploring the emotional and psychological aspects of chronic illness can be revealing.



The Power of the Mind


I once had a patient with severe rheumatoid arthritis who had seen ten rheumatologists before me. He was angry and in significant pain. Instead of immediately suggesting a new treatment, I asked him to consider if his condition had brought anything positive into his life. He thought I was crazy but came back three months later in near remission, having taken the treatment and reflected on the positives.



Emotional Acceptance


Accepting the positives that a condition might bring can sometimes facilitate healing. Chronic conditions often teach us valuable life lessons, prompting changes that improve our overall well-being. Embracing these lessons can help in letting go of the condition's hold.



Practical Steps


Listen to Your Body: Rest when needed, push when appropriate, but always listen to what your body tells you.

Embrace Positivity: Visualize yourself healthy and in remission. The placebo effect, with a 30% efficacy, demonstrates the power of the mind.



Conclusion


Achieving remission in psoriatic arthritis involves ensuring a correct diagnosis, treating the appropriate condition, and trying a variety of biologics. Reflecting on the emotional and psychological aspects of your condition can also play a crucial role. Embrace positivity and the lessons your condition teaches you and consider both clinical and holistic approaches to treatment.


Remember, the journey to remission is complex and multifaceted. Keep working closely with your rheumatologist, stay open-minded, and maintain hope.


This blog aims to shed light on the challenges and approaches in achieving remission in psoriatic arthritis. By exploring clinical and emotional aspects, we hope to provide a comprehensive perspective for those struggling with similar issues.




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