The main treatment target in spondyloarthritis, including ankylosing spondylitis (AS) and psoriatic arthritis (PsA), should be disease remission/inactive disease, according to a report by an international task force the 2013 annual meeting of the European League Against Rheumatism (EULAR) in Madrid.
Basing their judgments on a systematic literature review, a task force of expert physicians led by Josef S. Smolen MD of the Division of Rheumatology at the Medical University of Vienna also agreed on an alternative treatment target of low/minimal disease activity, discussing a variety of ways to assess these.
Published in the Annals of the Rheumatic Diseases just prior to EULAR, the recommendations make 11 recommendations based on outline five overarching principles.
1. Treatment targets should be based on shared decision-making between patients and rheumatologists, outlining reasons for recommending a particular target, therapeutic options for achieving it, and any treatment and disease-related risks. This principle had the highest level of agreement.
2. Because SpA and PsA are often complex systemic diseases, rheumatologists should collaborate with other specialists as needed to manage their musculoskeletal and extra-articular manifestations.
3. The primary treatment goal is to maximize long-term health related quality of life and social participation by
• controlling symptoms,
• preventing structural damage, and
• normalizing or preserving function
while avoiding toxicity and minimalizing comorbidities.
4. The outcomes can be optimized by halting inflammation, which "conveys the best outcomes."
5. Measuring disease activity with validated instruments and adjusting therapy accordingly helps to optimize these outcomes.
In AS, the instrument can be the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) or the Ankylosing Spondylitis Disease Activity Score (ASDAS). For PsA, the panel recommends well-validated scores such as the Disease Activity index for Psoriatic Arthritis (DAPSA). The task force advises regular follow-up examinations to validate changes in disease activity.
The panel offers an algorithm for treating to target in their publication. Dr. Smolen and co-authors stress that their literature review merely provides indirect evidence, failing to any studies that compared strategies to establish treat-to-target goals.
A research agenda should focus on strategic therapeutic trials and addressing missing information, such as defining disease activity states in PsA, they conclude.