336: Early Signs & Symptoms Of Psoriatic Arthritis (Don’t Ignore These!) w/ Dr. Jenny Bennett

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If you have psoriasis, you have a 30% chance of developing symptoms of psoriatic arthritis!

This type of psoriasis is notoriously difficult to diagnose because, unlike rheumatoid arthritis, there are no blood tests to easily confirm it.

Psoriatic arthritis can be triggered at any age, but its onset is most commonly between 35 and 55 years old. One of the early signs and symptoms of psoriatic arthritis is joint pain that gets worse over time until the joints become swollen and inflamed.

It might surprise you, but diet and medication can both trigger psoriatic arthritis, as well as GI tract microbiome imbalances (yes, this includes the mouth microbiome!)

Joining me to talk all about the symptoms of psoriatic arthritis and getting diagnosed sooner rather than later is Dr. Jenny Bennett, a naturopathic doctor, acupuncturist, and founder of Aria Integrative Medicine, an autoimmune specialty clinic in Seattle, WA. She utilizes treatments from both Eastern and Western medical practices to find the best approach for treating autoimmune diseases.

Dr. Bennett treats a wide variety of conditions such as Hashimoto’s thyroiditis, Graves’ Disease, rheumatoid arthritis, psoriatic arthritis, lupus, and scleroderma.

 

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In This Episode:

• Psoriatic arthritis: What is it + what are early signs/symptoms?
• Joints commonly impacted by psoriatic arthritis
• Psoriasis + psoriatic arthritis triggers (Don’t ignore these!)
• Stages of psoriatic arthritis + getting diagnosed (before too much damage is done)
• Liver-Psoriatic arthritis connection
• Gut triggers for symptoms of psoriatic arthritis
• Treatment of psoriatic arthritis
• If you take methotrexate, get THIS tested
• Exercise + other lifestyle interventions for psoriatic arthritis
• Pros + cons of using a biologic medication for psoriatic arthritis

Quotes

“There are a number of other medications that can sometimes impact liver function and can ultimately lead to… psoriatic arthritis. And there aren't very many anti-inflammatories that are very effective for psoriatic arthritis and, in fact, some of those anti-inflammatories can trigger psoriatic arthritis.”

“If you have psoriasis and you start having joint issues, then the bridge to getting a psoriatic arthritis diagnosis is straightforward. But there are up to 30 to 40% of people with psoriatic arthritis that have never had psoriasis in their life..”

Links

Find Dr. Bennett online | Instagram | Facebook | TikTok

Healthy Skin Show ep. 217: Health Concerns Linked to Psoriasis (You SHOULD Know About)

Healthy Skin Show ep. 304: Gut Microbiome Impact On Psoriasis w/ Dr. Fabrizio Galimberti

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5774610/

https://www.jrheum.org/content/early/2019/10/08/jrheum.181312

https://www.jaad.org/article/S0190-9622(21)00343-1/fulltext

 

336: Early Signs & Symptoms Of Psoriatic Arthritis (Don’t Ignore These!) w/ Dr. Jenny Bennett {FULL TRANSCRIPT}

Jennifer Fugo (00:06.904)

Hi, Dr. Bennett. Thank you so much for being here today.

Dr. Jenny Bennett (00:11.074)

Hey, I'm super excited to be here.

Jennifer Fugo (00:14.01)

Well, I am excited to have you because this is the first-ever episode where we talk about psoriatic arthritis. I've talked a lot about psoriasis on the show, but I feel like this is slightly different. And I'm so glad that you actually deal with this in your practice and can speak not only from the research and the clinical knowledge, which I think is so important to have. So why don't we kick things off for those who might not be aware of what it is – what is psoriatic arthritis? What are some symptoms of psoriatic arthritis as well as risk factors that people need to know about?

Dr. Jenny Bennett (00:50.13)

Yeah, absolutely. I'm super stoked to talk about psoriatic arthritis because I feel like it's kind of a silent arthritis. It's technically an inflammatory arthritis and it looks a lot like rheumatoid arthritis, but it's a very different mechanism. People who have psoriasis are more at risk of developing psoriatic arthritis. So if you have psoriasis or if you've had psoriasis, approximately 30% of people who have psoriasis or have had it will develop psoriatic arthritis at some point in their life, which is a fairly big percentage.

And the other piece about psoriatic arthritis is that you don't even have to have psoriasis to have psoriatic arthritis. So if you have like a family history of psoriatic arthritis, like a parent, brother, sister, aunt, uncle or grandparent, you are now also at higher risk for developing psoriatic arthritis. And psoriatic arthritis can happen at any age. I've seen it in as young as, you know, teens, early 20s, up into 50s and 60s. But generally, it happens somewhere between the ages of 35 to 55. And because it's an inflammatory arthritis, early signs and symptoms of psoriatic arthritis usually are really inflamed and swollen joints, but it doesn't happen all at once. It's not like you wake up one day and you're like, “oh my God, my joints are really swollen and inflamed.” What most people start to notice is that one or two joints will start hurting over a period of time, maybe it gets a little bit stiff, maybe you wake up in the morning and you're like, oh, this knuckle, this one knuckle swelled up. Or maybe it is that you feel like your knee, I don't know, you did something weird or you tweaked your knee or something like that. Or maybe something gets a little bit red or looks like one finger is kind of twisting the wrong way for whatever reason.

And so it can present in a lot of different ways and kind of any time in life, but it's really, really challenging to diagnose because it has absolutely no blood tests that you can do that will confirm psoriatic arthritis. So a lot of people, especially if they're younger, you know, they go into the doctor, they're like, oh, I've got this like one finger that hurts or like this finger started hurting and the other finger started hurting. And they'll go in and they'll be like, ah, you're fine. You know, like maybe just did something to it, like you tweaked it. Maybe they'll run some blood markers for rheumatoid arthritis, which are more common and nothing comes up. And then people just kind of go about their day. And then eventually, if things start to get worse and more joints start to get flared up, then it's not until it gets much worse that you can officially make the diagnosis, which is usually like when you have X number of joints that are affected. These are the types of joints that are affected. And these are maybe the other things that we've ruled out. But it's really challenging to be able to diagnose it at times.

Jennifer Fugo (03:53.913)

And with the joint involvement, is it just the small joints that are impacted by psoriatic arthritis? It sounded like you mentioned a bunch of different joints, because I tend to think if somebody has RA (rheumatoid arthritis), that you’ll see the pictures of people holding their hands, and their finger joints, and so maybe it impacts the smaller, finer joints. But with psoriatic arthritis, can it impact any type of joint?

Dr. Jenny Bennett (04:30.858)

Yeah, and this is what makes it kind of tricky. So, characteristically, psoriatic arthritis, we started differentiating it from rheumatoid arthritis because it affects a lot of really small joints. But there's a key differentiating factor between psoriatic arthritis and rheumatoid arthritis, where the joints in the hands that tend to get affected, or the feet, tend to be the joints that are farthest away from like the middle of the hand. Where rheumatoid arthritis tends to be joints that are closer to the wrist, like the wrist and these joints that are kind of close, but psoriatic arthritis is like closer to the tips of the fingers. So when people start having joints that swell up towards the tips of the fingers, you get more concerned about psoriatic arthritis.

Psoriatic arthritis is part of a group of arthritic conditions called spondyloarthropathies, and that's like a mouthful of a word that I don't ever expect anyone to remember. But the key differentiating feature is that these joints, which include, or these conditions that often include ankylosing spondylitis, enteropathic arthritis, and reactive arthritis. They’re all connected to this inflammatory process that happens where all the tendons and ligaments connect to the joint. So instead of happening like inside the joint, like rheumatoid arthritis, it's around the joint. And so it can happen in any joint, big ones, small ones. Oftentimes the spondyloarthropathies that happen in the spine, this is one of the big characteristic features. And a lot of people have low back pain, that's part of the psoriatic arthritis process is just low back pain or difficulty with the hips or movement in that degree.

Dr. Jenny Bennett (07:07.666)

While psoriatic arthritis can affect every joint, a lot of times it affects the spine and the hips. And so a lot of people have low back pain.

Jennifer Fugo (07:32.74)

So you talk about how there are three triggers for psoriasis and psoriatic arthritis that you commonly see. And I think knowing some of the triggers could be helpful. Can you share with us what those are?

Dr. Jenny Bennett (07:48.734)

Absolutely. Yeah, so, before we talk about the psoriatic arthritis triggers, I think it's important to understand kind of how all autoimmune diseases work, which in its basic form is a genetic component plus an environmental component. So all autoimmune diseases, psoriasis and psoriatic arthritis, but, you know, lupus and rheumatoid arthritis and, you know, any other autoimmune skin condition as well, it all starts with a genetic component and an environmental component. You have to have both of those pieces to create an autoimmune disease, but the genetics don't determine 100% that you'll develop an autoimmune disease. You have to have the environmental triggers on top of that. And there are a number of them that can affect all different types of autoimmune diseases.

When I look at this group of conditions like spondyloarthropathies, they tend to have some main triggers that will deal with things like the gut microbiome. So understanding that the balance between the bacteria and the yeast in our GI tract and if there are imbalances there in the microbiome in our mouth, our stomach, our small intestine, if that happens then what ultimately can occur is it can trigger this inflammatory process that leads to psoriatic arthritis. There are also some pretty significant food and dietary triggers that can occur. So dietary triggers sometimes, I mean like the big internet dietary triggers can be often gluten, dairy, and eggs, but I like to point out that often we shouldn't just eliminate all those foods. It's a good idea to be able to kind of figure out if one food or not is triggering the autoimmune response or a piece of it, and then go from there.

Jennifer Fugo (09:45.732)

Okay, and in terms of possible psoriatic arthritis drug triggers, there are some for psoriasis that I've read about online like beta-blockers, lithium, anti-malarial drugs, even terbinafine, which is an antifungal. Is it possible that medications could be a trigger or is that not what you see very commonly?

Dr. Jenny Bennett (10:11.858)

No, I've seen a number of medications trigger psoriatic arthritis. I don't think I've ever seen things like beta-blockers or terbinafine trigger psoriatic arthritis, but there are a number of other medications that can sometimes impact the liver function, and impacting the liver function can ultimately lead to changes in the inflammation that lead to psoriatic arthritis.

And it's interesting because there aren't very many anti-inflammatories that are very effective for psoriatic arthritis and in fact some of those anti-inflammatories can trigger the psoriatic arthritis. So there are certain things like methotrexate, which is a very common drug used for psoriasis, sometimes can aggravate liver problems in psoriatic arthritis. And in some people, it can make psoriatic arthritis better, in some people, it can make psoriatic arthritis worse. There are certain types, generally, the traditional DMARDs that we use, things like leflunomide and azathioprine and hydroxychloroquine like Plaquenil, those don't work at all for psoriatic arthritis. In fact, sometimes they can make them much worse. Pretty much anything that affects the GI tract, antibiotics especially, can definitely make psoriatic arthritis worse.

Jennifer Fugo (11:46.956)

Okay, and in terms of progression, is psoriatic arthritis something that progresses with time, and is there a stage or point at which there's so much damage that you may not be able to reverse it?

Dr. Jenny Bennett (12:09.962)

Yeah, so with all inflammatory arthritic diseases, there's always the possibility for joint damage to happen. And if enough joint damage happens over a period of time, there's no coming back from that. Like that joint damage has happened and it's generally non-recoverable, until we get stem cells to work and then eventually like, we'll probably be able to regrow the joint. But until now, we can't do that. So the goal with psoriatic arthritis is always to try to prevent joint damage from happening initially, which makes diagnosis really tricky because you have to diagnose things early. And if you can't get the diagnosis early and it happens too late, and damage occurs, then there's no going back from that.

Jennifer Fugo (12:54.788)

Okay. It sounds like getting a psoriatic arthritis diagnosis sooner rather than later is paramount, yet there’s the challenge of there being no definitive tests. So as a doctor, how do you make a clear psoriatic arthritis diagnosis? Also you mentioned symptoms of rheumatoid arthritis versus psoriatic arthritis, how do you eventually determine between the two? I would assume if you have psoriasis and you start developing joint issues it might make it easier per se.

Dr. Jenny Bennett (13:30.266)

Yeah, yeah, absolutely. Like if you have psoriasis and you start having joint issues, then the bridge to getting a psoriatic arthritis diagnosis is straightforward. But there are up to 30 to 40% of people with psoriatic arthritis that have never had psoriasis in their life. And so when they don't have that diagnosis, a lot of them get funneled into what we call seronegative RA, which is that you have rheumatoid arthritis with no lab markers. But many of those people don't have rheumatoid arthritis, they actually have psoriatic arthritis.

And so there are some key differentiating features I think are important to understand that happen with psoriatic arthritis that don't happen with a lot of the other inflammatory arthritis conditions. One of the big ones is nail changes. So looking at your nails is really important when you have psoriatic arthritis. So what often happens similar to psoriasis is you can get psoriatic changes in the nails that cause thickening of the nails or yellowing of the nails or they become brittle. Kind of looks like you have a fungal infection. Like a lot of people go in and they're like, “I have this fungal infection.” You're like, “no, that's actually just psoriasis or psoriatic nail changes.” And you don't actually have the skin psoriasis, you just have the nail changes.

Jennifer Fugo (14:48.228)

So you could just have psoriasis impacting your nails. Wow, I did not know that.

Dr. Jenny Bennett (14:53.71)

Yeah, and then one of the other big features is this psoriatic arthritis symptom called dactylitis, which is just what we call in lay terms sausage fingers. Essentially, it’s where the fingers swell up so bad that they look like a sausage. I always share this visual when teaching my rheumatology students. You know when you take a sausage and you cook it on the stove and it gets really tight and taut… before you poke it with a fork and it explodes with juice. Dactylitis causes your finger to look like that. So if your finger swells up and it gets really tight and really like you can't bend it at all and it becomes a little bit red, that's generally called dactylitis and that's a pretty common sign of psoriatic arthritis too. And that doesn't happen in rheumatoid arthritis or any of the other inflammatory arthritic conditions as well.

Jennifer Fugo (15:45.572)

And I wanted to ask you too about liver comorbidities because I really feel like people who have psoriasis should be very focused on knowing what's going on with their liver. And I really feel like for those with psoriatic arthritis, that could also be a factor. I actually came across this one paper from the Journal of Rheumatology, it was actually from 2019, and they said that about 32% of people with psoriatic arthritis had some sort of liver problem like non-alcoholic fatty liver disease or fibrosis. So what are your thoughts? Do you feel like this is something that if someone is diagnosed with this, they should really pay attention to?

Dr. Jenny Bennett (16:36.302)

Absolutely, yeah. And especially because a lot of the medications that people get put on that have inflammatory arthritis or psoriatic arthritis affect the liver, right? They can impact the liver also. So if you already have issues with your liver and then you add a medication on top, it creates just an undue burden. And I think a lot of it has to do with this GI connection to psoriatic arthritis, that if there is a lot of inflammation in the GI tract from the microbiome or from certain types of foods or from infections or things like that, then what can happen is it can create a burden on the liver and the gallbladder. And if that's the case, then it will create an increase in things like fibrosis and cirrhosis and hemangiomas, I've seen a lot of those, things like that.

Jennifer Fugo (17:28.568)

So if somebody's listening to this and they're like, wait, I just heard you talk about the gut and my joints. So if they were like, I maybe should start paying attention to that, could there be this gut connection to what's going on? And say they find a doctor or practitioner that is open to running like stool testing or something on them, that's not a crazy thing to consider in terms of this liver piece with psoriasis and psoriatic arthritis.

Dr. Jenny Bennett (17:59.314)

Absolutely not. I mean, we do it all the time in our clinic, is different types of stool testing. But pretty much, when someone comes in for psoriatic arthritis or psoriasis or any of the spondyloarthropathies, I am always looking at their gut first, always, because it is one of the biggest triggers for these types of autoimmune conditions. So if we need to do gut testing, and we need to look at the microbiome, it's not crazy at all. I've seen people who've had severe inflammation and swelling so bad that their hands can't function, just correct their microbiome and all of that swelling goes away.

Jennifer Fugo (18:39.776)

Wow, that's a big deal. I mean, obviously we're not trying to say that happens with everybody, but that is great to know that there is the potential for that. And do you find that there's any particular organisms, maybe, that we should, that you commonly see that maybe should in the future be on the radar in terms of this gut-psoriatic arthritis connection?

Dr. Jenny Bennett (19:08.894)

Yeah, that's an excellent question because I have been tracking these different types of microorganisms for years. And there used to be a fair amount of increase in certain types of bacteria like Citrobacter and Klebsiella. But since the pandemic, I have been seeing bacteria that I have not seen before start popping up, like Morganella and a lot more Pseudomonas than I ever saw before.

And also C. difficile. I've seen a ton of C. diff that people are not getting in the hospital, and they are getting C. diff walking around and they come in and their arthritis is way worse and then we treat the C. diff and it gets better, which is bonkers, because usually C. diff only happens when you're in the hospital. So yeah, it's been changing, but those are kind of the big ones I've seen in the past five or so years.

Jennifer Fugo (20:05.092)

That's fascinating. I always am fascinated by that because there's so many, you know, there's so much we don't know, which is exciting because then it's like things we can discover and find, but knowing that there is a connection between these kinds of conditions and these different organs or spaces in the body, it is all connected at the end of the day, is really fascinating. And I think it speaks toward that, and I'm sure you might be familiar with Dr. Heather Zwickey, she talked on the show a lot about how these inflammatory cytokines don't just start usually where we see or feel the pain or the joint tightness, or on the skin. They're really starting a lot of times someplace else, and the gut is not a place that you can just rule out. They absolutely can be triggered in the GI tract and then end up someplace distally because that's just how it works right now, unfortunately.

Dr. Jenny Bennett (21:05.042)

Absolutely, absolutely. In fact, well, it makes sense because approximately, you know, 70 to 80% of our immune system is in our gut. And that's just not just the stomach and small intestine and large intestine, that's also the mouth and throat and nose. So if you are having lots of inflammation and microtriggers to your immune system, it's going to flare up there and then it will go elsewhere in your body and cause problems.

Jennifer Fugo (22:58.72)

Let's talk a little bit about treatments and whatnot. And I wanted to ask you this question because we've talked about the liver issue in conjunction with psoriatic arthritis. And again, I'm Googling around, I'm always curious about things. And I happen to come across this situation called methotrexate hepatotoxicity, which methotrexate is a drug that might be used as one treatment option for psoriasis and psoriatic arthritis. And so in the Journal of American Academy of Dermatology, in 2021, they published this paper that said that those with psoriatic arthritis were 1.3 to 1.6 times more likely to develop mild liver disease and cirrhosis from taking methotrexate. Do you have any concerns or have you seen this show up in any of your patients?

Dr. Jenny Bennett (23:51.602)

Yeah, this is something that we do a lot is monitor medication side effects because a lot of the medications used can be pretty hard on the body. And methotrexate has been well known and researched in having pretty damaging effects on the liver over a period of time. I think it's important to note that there are two types of methotrexate you can take, though. There's an oral kind that you swallow and then there's an injection kind. And the kind that you swallow, like the pill, tends to have worse effects on the liver than the kind that you inject into your body. So there's that differentiation.

But like you had said before, people with psoriasis and psoriatic arthritis are at higher risk for having liver issues anyway. So if you give a drug with known hepatotoxicity to somebody who already has potential increase in liver issues, their chance of having problems with the liver are much higher. And methotrexate is probably the top or most used medication for psoriasis and psoriatic arthritis. Even though methotrexate doesn't have a lot of good data for psoriatic arthritis, even though it works well for psoriasis.

Jennifer Fugo (25:05.652)

Oh my, that is really troubling because many times when I talk to people who even just have psoriasis, they have no idea that there is even the liver component to all of this. They're usually pretty shocked. And so to find out that one of the more common medications, it's known that it could contribute even more to liver problems. Well, the things we know.

Dr. Jenny Bennett (25:31.242)

Yeah, I know, and anyone who is on methotrexate should be getting their liver enzymes checked every three months for the first one to two years. And if everything is good then they can just get it checked one year after that. But if your rheumatologist or your dermatologist is not checking those values at that consistent of a basis, you need to have someone else who can, PCP, ND, or somebody else. Because methotrexate can cause liver issues a year later, even if you don't see it on blood work when you first start it.

Jennifer Fugo (26:09.516)

When we say liver enzymes, are you saying that you would run a comprehensive metabolic panel to look at the AST, ALT? Do you also look at ALP or the alkaline phosphatase as well?

Dr. Jenny Bennett (26:23.102)

Absolutely, yeah. So the basic labs that we run for the liver come in, what you said, is a comprehensive metabolic panel or a CMP. And yes, we have three, well, two main liver enzymes, which are ALT and AST, and then alkaline phosphatase, which is ALP, which you can also use to kind of understand what's happening with the liver and bone. And then if there are other liver issues, there's another, they're all abbreviated, they got all these like weird abbreviations, there's GGT which is really important. But bilirubin is also really important, so like if you, that comes in a comprehensive metabolic panel too and if that's too high that will give you some information as to like how much of the liver function is affected.

Jennifer Fugo (27:09.604)

So that's good to know just to help people too, because sometimes they go to the doctor and they get a real quick once over and everybody's like, oh, it looks fine. And then you go and look at your labs, which sometimes people don't even look at their own labs, and maybe you start to track for yourself. I always think that's best because you might catch something or see a trend that's being missed in the shuffle of so many patients and go, hey, doc, you know, I noticed like two years ago things were here, but now today they're here, something's actually maybe going on, could we consider that? So I always think it's good, especially with such a basic panel that somebody at least know what they should be looking at themselves. Not that you can necessarily do anything other than talk to your physician, but I always think a second set of eyes, nobody's going to advocate for you, right, like you will for yourself.

Dr. Jenny Bennett (28:02.01)

Exactly, exactly. And if anything does come back elevated, I mean, bare minimum, just get it repeated in at least a month's time. And if it's still elevated, then really push hard because if you don't have a doctor that's willing to even retest you after a one month to make sure that those numbers aren't going back to normal, and it's not just a fluke, then you got to find someone who will do that for you.

Jennifer Fugo (28:24.96)

Now, are there any diet suggestions or like exercise or movement recommendations that you make for patients who have psoriatic arthritis?

Dr. Jenny Bennett (28:36.874)

Yeah, so exercise is incredibly important for all types of psoriatic, or not just psoriatic arthritis, but all types of inflammatory arthritis. So movement helps, the joint itself doesn't have a lot of good blood flow, so the immune system tends to get stuck inside the joint. And it's the movement that helps. One of the key defining features of inflammatory versus osteoarthritis, which is like the degenerative kind, is that when you move, things feel better.

So sometimes if there's joint damage, people will say, well, you know, my joints hurt, I don't really want to move. But almost always when they start to move, they feel much better. And everyone wants to try to get to a goal of somewhere around 30 minutes a day for a minimum of three days a week of just movement of the joint that is painful or has arthritis. You're not going to start there, but you got to work towards it because you need to be able to get there to a place where you’re moving it consistently and regularly. But then there's a balance, because you don't want to push yourself too hard because you could further damage the joint. So if you get to a place, and usually what I tell a lot of the patients I work with is, you know if you start to, if it feels a little stiff and tight in the beginning that's okay, push through, it will start to feel better. But if you start feeling pain into the exercise you have to stop, that is your cue to stop and you need to pull it back a little bit. And then you know for next time that that's kind of your border, so you can go up against that border and then push it a little bit each time but don’t go past that point of pain.

Jennifer Fugo (30:09.996)

Do you find that maybe physical therapy could also be helpful for people dealing with this or even possibly I'm thinking, as you said, there's not a lot of blood flow to the joints themselves, maybe some acupuncture? I found that acupuncture has been really helpful for my lower back, which I never thought of before until I ended up with a frozen shoulder and just happened to mention that I had lower back issues, and started doing some research about how acupuncture can actually help recruit in the immune system to areas where maybe we don't have as much innervation and whatnot, to like almost alert it to, hey, we need some cleanup help over here.

Dr. Jenny Bennett (30:50.91)

Yeah, well, I'm also an acupuncturist. So I'm a high advocate for acupuncture. So acupuncture is great, just like what you're saying, to increase movement into the joint, because if people really can't move, it is nice to have something that will help the blood flow in and out of the joint easier. Acupuncture is a great option for that. Hydrotherapy is a good option for that. So people doing, you know, well, cold plunges are really popular right now, but I don't generally recommend people do cold plunges. What we like to talk to people about is contrast, where you do like alternating between hot and cold, because the alternation just pushes the blood in and out of the joint. You had mentioned physical therapy which is awesome for people who have joint damage where they're afraid you know, that they're not going to be able to move that joint from here on out. Like once you get joint damage and you're worried that nothing will come back, physical therapy is the best thing you can do to help strengthen and tonify the area around the joint so it stabilizes it and future damage doesn't occur.

Jennifer Fugo (31:50.528)

Awesome. And then I have one more question. I feel like I have so many questions for you, but I'm just going to ask this one question, because obviously there are all of these pretty heavy-duty medications now out there. We talked about methotrexate, but there's also biologic meds now. There's a lot of them being used in psoriasis and I've seen others that get used for psoriatic arthritis. Do you feel like biologics can be helpful for people, maybe to prevent joint damage? What's the realistic view of them for somebody who is scared? Do you think that it should be considered as an option and how could it be helpful?

Dr. Jenny Bennett (32:37.89)

Yeah, that's an excellent question. So for a long time in conventional medicine, there wasn't a lot of good data to suggest that a lot of the biologics help prevent future joint damage. But now we do understand that some of them do. For a long time, we just used aspirin or NSAIDs because NSAIDs are one of the few things that actually do stop joint damage, but they cause a lot of problems if you take it long term. So we didn't want people on NSAIDs for a long period of time.

And so now some of the newer biologics that are coming out are fairly effective at reducing further joint damage, but those tend to be mostly the TNF alpha inhibitors, which is like your Enbrel and your Humira. And some of the newer cytokine inhibitors, like Xeljanz is a popular one for rheumatoid arthritis, that also is showing some promising effect for psoriatic arthritis. But it's really hard because a lot of the TNF, not just the TNF alpha inhibitors, but a lot of the biologics, what happens to people is they just, if one doesn't work, they just get shunted to the next one and shunted to the next one and shunted to the next one. And if you find that you're in that cycle where you just keep getting passed off to medication and medication and medication, then chances are good that most of those biologics are not going to be helpful for you. I've seen people go through this pattern way too often. My advice to people is usually, you know, if the disease is progressing, if it's happening at a rapid rate, if you're a younger age, it's sometimes a good idea to consider the biologics as first line therapy, taking other risk factors into consideration. And if they are effective, like the TNF-alpha inhibitors are effective, continue with those. But if you start cycling, then you have to do other things to try to reduce the inflammation that's not the biologics.

Jennifer Fugo (34:40.168)

Yeah, and may also thought that I always like to add to this, because I know sometimes people think they can only do one thing or the other. But I'm always like, well, if you're really struggling, right, you're really seeing this progression, you know, and I'm just speaking from experience with like psoriasis or eczema or some other condition, you could do the biologic and do some of this other work that you've talked about that is possible, to help with like the gut and the liver and all of these different things, that can be a helpful factor in reducing that inflammation, you know. And you just happen to have this helper tool on board to make life a little more manageable, a little more livable, you know, while you're doing the other work.

Dr. Jenny Bennett (35:28.034)

Absolutely, I mean, this is what I always tell the people I work with is the medications work fast, the other stuff works slow, they work amazing together and the goal is always to get you off the medication if it's possible. So if, say, making diet and lifestyle changes and correcting your gut microbiome and correcting your hormones and doing all this stuff that we need to do takes maybe like six months to a year, then we put you on the medication early to stop that joint damage in that year’s time, and then once we get you to a stable place we start removing it. And if you do fine on that then you might not need it at all afterwards.

Jennifer Fugo (36:06.44)

Well, thank you so much for sharing that, because I think that gives people hope and it also helps get them out of that black-and-white thinking that it's got to be one thing or the other thing. I always think people are encouraged when they hear, oh, I can actually do this together and they could compliment one another, and you know I think that's important for people to hear. So I appreciate you so much for coming on the show and talking all about this. I feel like you're gonna be back, because we have other things that I wanna ask you loads of questions on.

Dr. Jenny Bennett (36:35.745)

I mean, I love arthritis, I love autoimmune diseases, and yeah, it's just something I could talk about for hours.

Jennifer Fugo (36:43.56)

I can tell, I can tell. So where can everybody find you?

Dr. Jenny Bennett (36:47.818)

Yeah, so I run a clinic in Seattle, Washington called Aria Integrative Medicine. I also teach at Bastyr University Rheumatology there, so you can also find me at Bastyr. And we are on the socials like Instagram, Facebook, and TikTok as well.

Jennifer Fugo (37:13.484)

Perfect. We'll add your links in the show notes so people can connect with you and you are accepting patients, so if someone is interested, they can always reach out to your office and get connected. That's part of what I love about the show. Thank you so much, Dr. Bennett, for being here. I really appreciate it.

Dr. Jenny Bennett (37:41.098)

Yeah, thank you for having me. This was great. Thank you.