Delays in diagnosing and treating psoriatic arthritis – a common inflammatory disorder affecting 112 in every 100,000 adults – are causing irreparable damage to people's health. This damage could be avoided by catching the condition earlier and treating it effectively, according to research led by scientists in the Department of Life Sciences at the University of Bath in the UK. The new study , published today in the Annals of the Rheumatic Diseases, evaluated exactly where diagnostic delays are occurring as well as the treatments people are receiving. The results confirm a suspicion long held by the authors: that early symptoms of psoriatic arthritis (PsA) often persist for some time before the condition is diagnosed and treated. The researchers are calling for improved diagnostic systems to be established, where people with PsA and the doctors treating them are supported to recognise the initial phases, and diagnostic scans are offered earlier. A prompt response can prevent joint damage, and reduce pain and inflammation, resulting in far better physical function and quality of life for most patients. The study was led by Dr William Tillett , researcher at the University of Bath and a consultant rheumatologist at the Royal National Hospital for Rheumatic Diseases (RNHRD), which is based at the Royal United Hospitals trust in Bath. He said: "Work from our group and other researchers shows that delays to diagnosis of just six months can result in worse physical function for a patient in ten years' time, so diagnosing and treating the disease early, to prevent structural damage and preserve function, is vitally important." He added: "This disease can have a massive impact on people's lives and make it difficult for them to work and manage regular daily activities." Visible signs of PsA appear months or even years before a person develops the full-blown condition, generally giving clinicians plenty of time to intervene with appropriate treatment. However, signs are variable and can include the rash of psoriasis, joint stiffness, lower back pain, fatigue, swollen fingers and toes, and changes to the quality of finger- and toenails. These signs can easily be confused for less serious chronic conditions, leading to misdiagnoses. As a result, valuable time is often lost before a patient is referred to a specialist, leading to delays in the diagnosis and treatment of PsA. Elaborating, Dr Tillett said: "With rheumatoid arthritis (another common arthritis), symptoms are quickly visible, so the condition is generally diagnosed without too much delay. It's harder to detect inflammation in the joints affected by psoriatic arthritis, as these joints – such as those in the spine – are often not visible to the eye, and it takes an ultrasound to see the damage. Too often, scans don't happen for some time after the patient starts noticing symptoms." For the new study, funded by Janssen Pharmaceuticals, the authors collaborated with the British Society of Rheumatology and National Early Inflammatory Arthritis Audit to evaluate people who were diagnosed with PsA between May 2018 and October 2019, and explore why there were delays in diagnosis. The reasons were found to be multiple: people are slow to present to their GP with symptoms and once patients find their way to a specialist, there is a long wait before diagnostic tests are carried out. The reasons for the delays between seeing a specialist and undergoing a scan remain unclear. The researchers plan to investigate this issue further in future studies. The research team believes screening people at high risk of developing psoriatic arthritis along with more streamlined diagnostic facilities are essential interventions to stop the occurrence of irreversible damage. Dr Rachel Charlton , the study's first author and a life sciences researcher at Bath, said: "We need more education around clinicians assessing people with arthritic symptoms and better access to scans. We also need to focus on early intensive treatment before damage sets in – there is a window of opportunity that we may be missing at the moment." In future work, the researchers plan to probe the experiences of patients and clinicians in the face of PsA, to develop a fuller picture of the reasons behind diagnostic delays. Predicting a patient's risk In a separate study on PsA , also published this month, researchers from the University of Bath and the RNHRD investigated the possibility of predicting a patient's risk of developing PsA based on information collected routinely by family doctors. Alex Rudge , a PhD student in the Department of Mathematical Sciences at Bath, used a statistical model (a system for analysing data) to interpret information from a massive database originating from primary-care practices across the UK. His model found some important indicators of PsA – including patterns of symptoms and medicine use – that may in time help clinicians identify a person at risk of developing PsA. It is hoped that a software tool will eventually be developed to flag at-risk patients to their GP, thereby reducing the time between experiencing early symptoms and diagnosis. Mr Rudge said: "The software would say: We've identified a person who is showing an interesting pattern, based on their symptoms and prescriptions – have you considered psoriatic arthritis?" Improving detection of debilitating diseases and improving outcomes are priorities for most countries in the global north and are at the heart of the NHS long-term plan in the UK. "If clinicians were to focus their attention on people who are considered at higher risk, they could be more targeted in the way they care for patients, and screening would be more cost-effective for the health service," said Dr Tillett, who supervised the database project. Dr Liz Price, national clinical lead for the National Early Inflammatory Arthritis Audit (NEIAA) at the British Society for Rheumatology, said: "The NEIAA has been running since 2018 with the aim of improving standards of care for patients with early inflammatory arthritis. From the outset it was apparent that early treatment improved outcomes and 60% of patient in England and Wales now start disease modifying drugs within 6 weeks of treatment. However, variation in care still exists and it is really important that we understand the factors behind this to ensure that care is improved for everyone with inflammatory arthritis. Studies such as these which utilise the data collected by the audit are an important way of identifying sub-groups where care is suboptimal, raising awareness and allowing targeting of resources to improve outcomes across the patient population." The study by Alex Rudge was funded by the pharmaceutical company UCB. Background note: Psoriatic arthritis is an autoimmune condition and should not be confused with regular psoriasis. Psoriasis is a chronic skin condition that causes the rapid buildup of skin cells, leading to patches of red or discoloured skin covered with thick, silvery scales. One in four people with psoriasis go on to develop PsA. |
