Physicians Forgo Psoriatic Arthritis Treatment Adjustments

Remaining disease activity was present in almost two-thirds of patients with psoriatic arthritis in a recent study when disease activity parameters were scored by the treating rheumatologist.

Although options for treatment changes are available, the researchers found that treatment is not adjusted for a large majority of patients who have residual disease activity.

Treatment options for patients with psoriatic arthritis increased significantly over the past decade, they noted. Leflunomide and tumor necrosis factor (TNF) inhibitors became part of the standard therapeutic arsenal, and several other new treatments-including ustekinumab, apremilast, and secukinumab-became available.

Also, the Tight Control of Psoriatic Arthritis (TICOPA) trial demonstrated that the availability of treatments and the strategy on how to use them determines the clinical outcome. The treat-to-target arm showed significantly better outcomes in peripheral arthritis, skin, and patient reported outcomes than the standard-care arm.

Reports indicate that not many patients are in a minimal disease state in spite of receiving treatment in a clinical practice, the authors stated. Possible reasons for residual disease activity include (1) patients are not responding to all available treatments; (2) comorbidities, adverse effects, and incompliance are resulting in patients’ inability or unwillingness to use available medications; and (3) the currently available treatments are not being used optimally.

The researchers conducted the study to assess current clinical practice on defining residual disease in patients with psoriatic arthritis and making subsequent treatment decisions.

They reported their findings in a recent issue of Arthritis Research & Therapy.

The study

The cross-sectional study scored disease activity and treatment decisions prospectively in 142 consecutive patients with psoriatic arthritis who visited an outpatient clinic for routine follow-up. Disease activity parameters were scored by the patient and the treating rheumatologist. The rheumatologist also registered an opinion on the presence of remaining disease activity in spite of current and subsequent treatment decisions.

The treatment options available in clinical practice during the inclusion period were limited to conventional disease-modifying antirheumatic drugs (csDMARDs), such as methotrexate and leflunomide, and TNF inhibitors. Because ustekinumab became available for use in clinical practice just before the study, this was not a common drug to prescribe at that time.

Results

Following are some of the results:

• Two-thirds of the patients had remaining disease activity according to the treating rheumatologist.

• Close to half of the patients had moderate to high disease activity according to the clinical Disease Activity Index for Psoriatic Arthritis (cDAPSA).

• Residual disease activity was determined by joint disease and pain, not by active psoriasis.

• Demographic and clinical features were similar in the groups that had and did not have residual disease.

• Among patients with remaining disease activity, 74% were treated with a csDMARD only or a first TNF inhibitor, suggesting opportunities for treatment modification, but treatment adjustment was initiated in only 23% of the patients who had residual disease.

• No differences in objective disease activity measures, such as joint counts and patient scores, were found between patients who had and did not have remaining disease activity.

The researchers concluded that decisions not to adjust treatment in spite of residual disease activity are driven by subjective opinions of the rheumatologist or the patient or both, rather than comorbidities or a lack of treatment options, in a vast majority of patients.

Alternative reasons they offered for physicians not adjusting treatment included a lack of structural disease activity assessment in clinical practice, limited availability of evidence that aggressive treatments result in improved short- and long-term clinical outcomes, and poor implementation of guidelines and treatment strategies in clinical practice.

The authors suggested that more research is needed to understand why disease activity does not lead to treatment adjustment to enable implementation of treatment strategies in clinical practice.

References:

van Mens LJ, van de Sande MG, Fluri IA, et al. “Residual disease activity and treatment adjustments in psoriatic arthritis in current clinical practice.” Arthritis Res Ther. 2017 Oct 10;19(1):226. doi: 10.1186/s13075-017-1424-8.