Challenges in managing Psoriatic arthritis in the Indian setting

Pravin Patil MRCP, FRCP, CCT-Rheumatology
Consultant, Pune Rheumatology Centre, Pune

In the Indian setting, managing Psoriatic arthritis (PsA) poses several unique challenges in diagnosis, treatment and overall management.

Delayed Diagnosis

The lack of awareness among both patients and frontline healthcare professionals about PsA leads to the under-recognition of the condition. Patients often seek treatment from dermatologists for psoriasis-related skin manifestations, while joint symptoms may go unnoticed or be attributed to other conditions. It is not uncommon for patients to be treated for psoriasis by a dermatologist and (wrongly labelled) “rheumatoid arthritis” by another practitioner.

Symptom onset to DMARDs institution time

The use of alternative therapy as the first line of treatment for psoriasis and PsA is a common practice among many patients. This preference for alternative therapies can lead to delays in the initiation of conventional therapy with DMARDs.

Referral inertia

Patients often reach rheumatologists in advanced stages of their illness. Just like poor adherence to medications, which is attributed to the attitude of the patient, referral inertia is caused by the attitude of treating doctor. Late referral to rheumatologists is not uncommon in our country. A ‘window of opportunity’ for early intervention is often lost in most cases. 

Limited Access to Rheumatologists

In some regions, access to rheumatologists and specialized care may be limited. Patients may rely on general or other practitioners or alternative healers who are more accessible and familiar to them. This disparity in healthcare resources contributes to delayed diagnosis and suboptimal management of the disease.

Socioeconomic Barriers

The cost of PsA treatment, particularly biologic therapies, can be prohibitive for many patients in India. These medications are often not covered by government health schemes or insurance plans, which makes them inaccessible to a significant proportion of the population.

Lack of Treatment Guidelines

While international guidelines for PsA management exist, there is a need for specific guidelines tailored to the Indian context. Cultural practices and the healthcare infrastructure may influence treatment decisions. The absence of locally adapted guidelines may lead to variability in treatment approaches among healthcare professionals.

Patient education

In India, cultural beliefs, lack of understanding of the chronic nature of the disease, and fear of side effects may lead to poor treatment adherence. Patients who have not visited a rheumatologist may not be aware of the link between joint pain and psoriasis. Thus, they do not volunteer this information from other specialists due to lack of awareness.

Expectations from the treatment

A significant level of disconnect in terms of ‘therapeutic outcome expectations’ is seen in many patients. Most patients seek complete cure of the disease with zero risk of side effects. Patients are not equipped with enough knowledge and patience to weigh up risk-benefit ratios of advanced treatment options like biologics. This calls for measures to intensify treatment awareness among the patients and improve the counselling time and techniques. Educating patients may help patients have realist expectations from the treatment and enable informed decision-making.

In conclusion, managing psoriatic arthritis in an Indian setting is marked by delayed diagnosis, limited access to specialists, socioeconomic barriers, lack of locally adapted treatment guidelines, and unique challenges related to patient beliefs and cultural practices. Addressing these challenges requires concerted efforts from healthcare professionals, policymakers, and patient advocacy groups to improve awareness, access to specialized care, and affordable treatment options. Developing tailored guidelines and increasing research efforts are essential to enhance PsA management and ultimately improve patient outcomes in India.

Suggested reading:

  1. Rajagopalan M, Dogra S, Godse K, Kar BR, Kotla SK, Neema S et al. Therapeutic Inertia in the Management of Psoriasis: A Quantitative Survey Among Indian Dermatologists and Patients. Psoriasis (Auckl). 2022 Aug 25;12:221-230.
  2. Elmamoun M, Eraso M, Anderson M, Maharaj A, Coates L, Chandran V et al. International league of associations for rheumatology recommendations for the management of psoriatic arthritis in resource-poor settings. Clin Rheumatol. 2020 Jun;39(6):1839-1850.
  3. Pathak H, Goyal M, Das P, Santhanam S, Khan AK, Malaviya S et al. Awareness, perspectives and satisfaction levels among patients with psoriatic arthritis: a multicentric cross-sectional survey. Rheumatol Int. 2023 Aug;43(8):1531-1539.