Clinical Challenges –
5th in a Series

Case Study: Onset of Psoriasis in a Female Patient with Challenging Treatment Situations

Authors
Terry Arnold, MA, PA-C; Chris Englert, RN, NP;
Craig L Leonardi, MD

      

Target Audience
This CME/CE activity has been designed to enhance the patient management skills of Nurse Practitioners and Physician Assistants who treat patients with psoriatic conditions. 

Credits Available: CME/CE
This activity is certified for both Nurse Practitioners and Physician Assistants.

Original Release/Expiration Dates
October 30, 2008; Valid for credit through October 30, 2009

The persistence of psoriasis as a lifelong problem often translates to a frustrating condition for patients and clinicians.  As awareness of the devastating impact psoriasis may have on patients’ lives increases, healthcare professionals are becoming evermore sensitive to the emotional response associated with the conditions.  The focus on quality of life is an important part of the overall care of the patient, and its positive achievement should be a key therapeutic goal.

Other issues are also gaining prominence in psoriatic disease management.  The relationship between psoriasis and co-morbid conditions is one such topic, with epidemiologic research revealing prevalence rates of cardiovascular disease, obesity, diabetes mellitus, and lymphoma to be higher among individuals with psoriasis than among those without the condition.  The increases risk of these diseases suggests the existence of an inflammatory process not restricted to the skin but also observed systemically with metabolic and vascular abnormalities.  This speculation is further supported by the concurrent existence of psoriatic arthritis, colitis, and uveitis among many patients with psoriasis.

Effective treatment for psoriasis has been available for many years, and patients often respond well to medical intervention.  Biologics are now proving advantageous for many patients above and beyond outcomes observed with traditional agents.  Long-term studies are generating data that indicate biologics are safe and effective for use over extended periods of time.  Long-term therapy requires regular reevaluation of patient response to note when treatment modifications are required.  Combination therapy is one of the treatment strategies gaining popularity for long-term disease management.  Reports are showing the addition of a second medication is beneficial for patients who continue to do well with their original medication but require a second agent to augment the response. 

Nurse Practitioners and Physician Assistants play an important role in today’s busy dermatology office.  Often, these healthcare professionals diagnose and manage patients that traditionally have been seen only by the physician.  Dermatology NPs and PAs have expressed a need for further education in the area of inflammatory dermatological disorders and the use of novel therapies.  Evaluation of previous issues of Clinical Challenges CME activities provided to this audience has demonstrated that evidence-based educational content that can be practically applied truly meets the learning needs of these healthcare professionals because of the pragmatic nature of the case-based format.  In addition, these clinicians particularly appreciate content focusing on the psychosocial aspects of dermatological disease states, an area often ignored in education programs.  An enduring material program designed to provide a national audience of dermatology NPs and PAs with both evidence-based clinical data from the latest published literature and demonstrative practical case histories that illustrate appropriate uses of anti-TNF therapies as well as all aspects of dermatological conditions exposes practitioners to the information they need in a format they can use.

Terry Arnold, MA, PA-C
Advanced Practice Consultants
Tulsa, Oklahoma

Chris Englert, RN, NP
North Baltimore Dermatology
Baltimore, Maryland

Craig L Leonardi, MD
Associate Clinical Professor of Dermatology
Saint Louis University
St Louis, Missouri

In direct response to the September 2004 Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support, CME Consultants issued a conflict of interest policy dated January 2, 2005.  The policy states that the disclosure of potential financial conflicts of interest within the last 12 months must be made and resolved prior to date of the CME/CE activity where commercial support grants are to be used to fund the activity.  The following conflicts have been managed and resolved through the Independent Review Committee of CME Consultants. Our intent is to assist learners in assessing the potential for bias in information that is presented during the CME/CE activity.

The faculty is also aware it is their responsibility to inform the audience if discussion of any non-FDA approved uses of pharmaceutical, medical equipment, prostheses, etc., will be included in their presentation. 

Terry Arnold, MA, PA-C
Discloses the following:
Advisory Board/Speaker: Abbott Immunology, Amgen Inc, Astellas Pharma US Inc, CollaGenex Inc, Coria Laboratories Ltd, Genentech Inc, Ranbaxy

Advisory Board: Centocor Inc, Novartis, Warner Chilcott 

Consultant: Amgen Inc, Coria Laboratories Ltd, Intendis            

Speaker: Medicis                                     

Shareholder: Amgen Inc, Genentech Inc, Stryker

Honoraria (Speaking/Consulting Fees): Abbott Immunology, Amgen Inc, Centocor Inc, CollaGenex Inc, Coria Laboratories Ltd, Genentech Inc, Ranbaxy, Warner Chilcott

Chris Englert, RN, NP
Discloses the following:
Honorarium: Amgen Inc, Burroughs-Wellcome

Craig L Leonardi, MD
Discloses the following:
Advisory Board/Consultant: Abbott Laboratories, Amgen Inc, Centocor Inc, Genentech Inc

Principal Investigator: 3M Pharmaceuticals, Abbott Laboratories, Allergan, Altana Pharma, Alza, Amgen Inc, Astellas Pharma US Inc, Bristol-Myers Squibb, Celgene, Centocor Inc, CombinatoRX, Eli Lilly, Galderma, Genentech Inc, Novartis, Perrigo Israel Pharmaceutical, RTL, Schering-Plough, Vitae Pharmaceuticals, Wyeth Pharmaceuticals

Honoraria/Speaker’s Bureau: Abbott Laboratories, Amgen Inc, Centocor Inc, Genentech Inc, Warner Chilcott

Physician Assistants
This program was planned in accordance with AAPA’s CME Standards for Enduring Material Programs and for Commercial Support of Enduring Material Programs.

Nurse Practitioners
This activity was planned in accordance with AANP’s CE Standards for Enduring Material Programs and for Commercial Support of Enduring Material Programs.

This program has been reviewed and is approved for a maximum of one hour of AAPA Category 1 CME credit by the Physician Assistant Review Panel.  Approval is valid for one year from the issue date of October 30, 2008.  Participants may submit the Post-Test at any time during that period.

This program has been approved for 1.0 contact hours of continuing education (which includes 0.5 hours of pharmacology) by the American Academy of Nurse Practitioners.  Program ID 0806270.

This activity is jointly sponsored through CME Consultants and Educational Awareness Solutions®.

The estimated time to complete this activity, including the Post-Test, is 1 hour.

This Clinical Challenges is intended to broaden the participant’s knowledge of psoriatic conditions, enhance skills in caring for and counseling patients, and develop a high level of comfort in addressing issues of concern to the patients and their families.  At the conclusion of this activity, the participant should be able to:

1. Recognize the negative impact psoriatic disease has on patient quality of life
2. Differentiate the systemic pathophysiologic abnormalities associated with psoriasis
3. Describe the relationship between psoriasis and various co-morbid conditions
4. Identify the potential benefits of combination therapy for the treatment of patients with psoriatic disease to achieve optimal patient outcomes

The contents of some CME/CE activities may contain discussions of nonapproved or off-label uses of some of the agents mentioned.  Please consult the prescribing information for full disclosure of approved uses.

This activity is supported by an educational donation provided by Amgen and Wyeth Pharmaceuticals.