Case Study: 53-year-old woman with rheumatoid arthritis

Rheumatoid Arthritis Case Study

"So why is this study important? For me it's important because it lays the foundation for personalized medicine. We known that patients have a window of opportunity where we can maximally improve their disease and get it under control. But once they have long standing disease, it gets much harder to bring the disease under control. Ideally, we would like to identify what drugs patients should be getting as soon as possible based on their clinical profile and this is a much better approach than a trial and error approach to this selection of medications.

So the shared epitope, or SE, is a major risk factor for rheumatoid arthritis. It is associated with the production of anti-citrullinated protein autoantibodies (ACPAs) in patients with RA. In the early AMPLE trial, among ACPA plus patients with early RA, efficacy responses with abatacept (ABA) but not adalimumab were numerically higher in patients who were SE positive versus those who were SE negative.

The goal of this study was to explore that same topic in a real world cohort, in particular, we used data from patients enrolled in the Corrona CERTAIN study and looked at their improvement in disease activity. In this study, we used the CDAI index as a measure of disease activity and looked at change from baseline to six months among moderate to severe RA patients who were both ACPA and SE positive and initiated abatacept or TNF inhibitors. 


We found numerical improvement in ABA versus TNF inhibitors in most of the efficacy outcomes over six months. In these patients with long-standing rheumatoid arthritis who were both SE and ACPA positive. We did the analyses a couple of ways and saw these similar trends. So we did propensity score (PS) trimmed cohorts to maximize the sample size and we also did propensity score matched to do a more select group.

When we adjusted for covariates that remained imbalanced between the groups, in the biologic-experienced propensity scored trimmed cohorts, the improvement is CDAI score with ABA versus TNF inhibitors was significant meaning we saw more improvement with ABA than the TNFs.

Based on these results, it suggests there may be a benefit to using abatacept rather than cycling through a subsequent TNF in the management of biologic-experienced patients who are post SE and ACPA positive.

Now, of course there are some caveats. As with any research in an emerging topic we would suggest that the study be replicated in other patient populations. In addition, there are still some unanswered questions and we hope that there is further research exploring this further. For example, it's not clear what the relationship between the shared epitope and ACPA is. For example, could ACPA just be a marker of the shared epitope. Or, do they both work to impact response to medications or could their be a synergistic relationship. It's not clear. We also don't know if the number of copies of the shared epitope make a difference.

And, we do hope there is further exploration into this are by our group and others."

"At the end of the day, what I think is most impactful about it, is that it's starting to help us identify that there could be biomarkers or patient characteristics that help us make better decisions about what drugs people should be on. At the end of the day, as I said before, giving the right drug at the right time for patients is really the key. I think this abstract really gives that glimmer of hope that we will be getting there and are able to provide more personalized treatments to patients."

"The Comparative Effectiveness of Abatacept versus TNF Inhibitors in Patients Who Are ACPA Positive and Have the Shared Epitope: Results from a US National Observational Study."

 ACR Convergence 2020. Saturday, November 7, 2020



Videos

In rheumatoid arthritis, physician scientists are beginning to zero in on personalized medicine. In this interview, Dr. Leslie R. Harrold, chief scientific officer of Corrona, and a University of  Massachusetts associate professor, summarizes a study she recently presented at ACR 2020 in which she describes biomarkers and patient characteristics she and her team have identified as taking us one step closer to precision medicine.


One Step Closer to Precision  Medicine in RA

Patients with early rheumatoid arthritis and no history of cardiovascular have signs of vascular stiffness which improve with DMARD treatment, and the effects seems to be independent of rheumatoid arthritis disease activity and treatment response, shows a study published in the 

“Our research highlights the importance of commencing treatment of rheumatoid arthritis early in order to also lessen the risk of developing cardiovascular disease,” said lead researcher Maya Buch, professor of rheumatology and Director of Experimental Medicine at the Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health at the University of Manchester, UK.

Patients with rheumatoid arthritis have a greater risk of premature cardiovascular disease (CVD), especially atherosclerosis and heart failure, and the magnitude of increased risk is similar to that associated with major CVD risk factors such as type 2 diabetes. It has been suspected that this heightened risk is mediated by inflammation, raising the possibility that rheumatoid arthritis immune-modulating therapies could influence CVD pathogenesis.

The researchers used cardiovascular magnetic resonance (CMR) - the most sensitive tool for the assessment of CVD – to determine whether 81 treatment naïve patients with early rheumatoid arthritis exhibited any myocardial or vascular changes compared with patients without rheumatoid arthritis. Thirty healthy volunteers, age and sex matched to the first thirty early rheumatoid arthritis patients and who had no history or risk factors for CVD, acted as controls.

RELATED: DMARD Treatment for Early RA Improves Heart Disease

The patients with rheumatoid arthritis were enrolled in a phase IV trial comparing first-line etanercept (ETN) plus methotrexate (MTX) with methotrexate alone in early rheumatoid arthritis. None had type 2 diabetes and all had no more than one traditional CVD risk factor.

The cardiovascular magnetic resonance assessments showed that both mean aortic distensibility (AD) and left ventricular (LV) mass were significantly lower in patients with early rheumatoid arthritis compared with controls, at 3.0×10−3 mm Hg−1 versus 4.4×10−3 mm Hg−1 and 78.2 g versus 92.9 g respectively, while extracellular volume (ECV) was increased at 27.1% compared with 24.9%.

The 81 patients with early rheumatoid arthritis enrolled in the phase IV trial were randomised to etanercept plus methotrexate (15 mg weekly, optimised to 25 mg weekly by week 8) or a methotrexate treat to target strategy (15 mg weekly increased to 25 mg weekly at 2 weeks with further escalation if indicated). Patients in the methotrexate treat to target arm were switched to etanercept plus methotrexate at week 24 if that had failed to go into remission (DAS28-ESR≥2.6).

After the trial had been running for one year, etanercept was stopped in all patients, and patients continued on standard of care for a further twelve months.

Patients were reassessed using cardiovascular magnetic resonance at the end of the first and second year to determine whether the myocardial and vascular changes detected at baseline had worsened, improved or stayed the same.

The results showed that average aortic distensibility had improved, increasing from 3.0×10−3 mm Hg−1 to 3.6×10–3 mm Hg−1 during the first year of rheumatoid arthritis treatment, and this improvement was maintained in the second year. There was no significant different in improvement between the two treatment arms and the size of improvement was also not influenced by the level of disease activity.

The fact that rheumatoid arthritis treatment improved vascular stiffness (an indicator of cardiovascular disease), regardless of how the patient responded to the rheumatoid arthritis medication, was “unexpected,” said Professor Buch. “It suggests that in addition to suppressing inflammation, rheumatoid arthritis treatments may influence CVD risk through other means. Maybe through changes to metabolic profile and/or a direct effect on the processes of heart and vascular disease.”

However, while vascular stiffness is an indicator of cardiovascular disease, it was too early to say whether the improvement shown in the study translated into a reduction in actual cardiovascular event so we should be cautious when tapering therapy, he added.

“Until further data are acquired, these data also suggest we should be cautious if considering a reduction in rheumatoid arthritis therapy (due to good joint control) for concern of risk of CVD progression. We should be cautious if tapering therapy – until we have specific studies that evaluate not only joint damage progression but also cardiovascular outcomes.”

Plein S, Erhayiem B, Fent G, Horton S, Dumitru RB, Andrews J, Greenwood JP, Emery P, Hensor EM, Baxter P, Pavitt S, Buch MH. Cardiovascular effects of biological versus conventional synthetic disease-modifying antirheumatic drug therapy in treatment-naïve, early rheumatoid arthritis. Ann Rheum Dis. 2020 Nov;79(11):1414-1422. doi: 10.1136/annrheumdis-2020-217653. Epub 2020 Aug 28. PMID: 32859608; PMCID: PMC7569379.

Articles

DMARDs improve vascular stiffness in patients with early rheumatoid arthritis regardless of impact on rheumatoid arthritis disease, shows new research published in the Annals of the Rheumatic Diseases.

Early RA Treatment Can Stave Off Heart Disease

Juana Mata was diagnosed with rheumatoid arthritis in April 2009. In May 2009 she ended up in the hospital with a variety of symptoms and was sent home with a diagnosis of anxiety because she insisted that something was wrong. She refused to go home unless she had testing done, after the testing was completed. She was admitted to ICU with platelet count of 2,000 (normal is 150,000-450,000), she was diagnosed with thrombocytopenia and systemic lupus. If she would have gone home that day she would have died. She was scared and knew very little about lupus, she wanted to learn, and empower others about self advocacy.

In this interview from Overdrive, the Rheumatology Network podcast, Dr. Kim Gorgens, a psychologist and Rheumatology Network board member, interviews Ms. Mata and her sister, Estela Mata-Carcamo, about their work to support, empower and educating women and men living with lupus.

The sisters recently presented their work at the annual meeting of the American College of Rheumatology, which took place last month.

 is Clinical Professor and Director of Continuing Education, Graduate School of Professional Psychology, University of Denver. For more articles from Dr. Gorgens, visit her blog 

 • ACR Convergence 2020. Date: Sunday, November 8, 2020. "Knitting a Community of Hope”- Supporting, Empowering and Educating Those Living with Lupus, and Overlapping Conditions and Their Loved Ones via in Person and Virtual Support Groups That Include Art Therapy, and Wellness Techniques Is Key; Mental Health Is as Important as Physical Health." Juana Mata (1) and Ma. Estela Mata-Carcamo (2), (1)Looms for Lupus, La Puente, CA, (2) Looms for Lupus, Baldwin Park, CA

Podcasts

In this episode of Overdrive, the Rheumatology Network podcast, Dr. Kim Gorgens interviews two sisters who've turned a negative healthcare experience into a positive force for change in the lupus community through advocacy. They shared their story during the Patient Perspectives session at the annual meeting of the American College of Rheumatology which was held last month. In this interview, they share their story with Dr. Gorgens.


Lupus Patient Perspectives:  Self Advocacy

Anxiety and depression are not uncommon among lupus patients, show studies recently presented at the annual meeting of the American College of Rheumatology.

A Chinese study presented by Yongfu Wang showed that a higher prevalence of anxiety and depression were associated with higher levels of disease activity in patients with systemic lupus erythematosus (SLE).

Like other studies presented at the meeting, the researchers designed novel tools and solutions designed to track symptoms. Dr. Wang, of Inner Mongolia University of Science and Technology, and his team designed a mobile tool called Smart System of Disease Management (SSDM) mobile app in which patients could track disease activity. They found that the higher the disease activity, the higher the anxiety. The mobile app proved to be a useful tool in tracking both conditions.

Lilian Cano-Cruz of the Instituto Nacional De Ciencias Medicinas y Nutricion Salvador Subirán in
Mexico City, compared lupus outcomes among female and male patients finding that females in this study had lower disease activity, but exhibited more anxiety and depression and lower quality of life as compared to men who had higher disease activity. "It is important that rheumatologists take these findings into account, in order to establish optimal support according to gender," researchers

Mental health symptoms should be addressed in rheumatic disease patients as a result of COVID-19, Shereen Mahmood wrote in her ACR 2020 abstract In this survey of 202 patients, 56 percent had at least mild symptoms of depression, 16 percent had moderate signs of depression, 12 percent had severe depression. 106 (48 percent) patients had at least mild symptoms of anxiety, 31 (14 percent) had moderate, 20 (9 percent) had severe. All mental health scales were moderately correlated with the COVID-related distress scale.

In a cross-sectional study of psoriatic arthritis patients 688 cases, physicians reported anxiety and/or depression in 14.2 percent of patients, while 36.6 percent of patients self-reported having anxiety and/or depression. Patients with anxiety and/or depression had worse QoL, higher work impairment, and greater disability.

After adjusting for demographic and clinical factors, patients with anxiety and/or depression were found to have worse quality of life, work productivity, and disability outcomes than those without. Differences between patient and physician reports of anxiety and/or depression suggest that physicians may not be aware of the extent to which PsA patients experience anxiety and/or depression," wrote authors who were led by Laure Gossec of Sorbonne University in Paris.

Disease Activity and Mental Health in SLE Patients: A Cross-section Study with Self-Assessments Based on Smart System of Disease Management (SSDM) Mobile Tools.

 Sex Differences in Mental Health and Quality of Life and Their Impact in the Treatment of Patients with Systemic Lupus Erythematosus
Lilian Cano-Cruz. Date: Sunday, November 8, 2020

. COVID-Related Distress and Mental Health in Adult Rheumatology Patients During the COVID-19 Pandemic. Shereen Mahmood

Anxiety and Depression in Psoriatic Arthritis (PsA) – Prevalence and Impact on Patient Reported Outcomes: Real-World Survey in the US and Europe
Laure Gossec.

Stress Can Take Its Toll Rheumatic Disease

Dr. Andrew Concoff brings tremendous range and unique experience to envisioning the future practice of musculoskeletal medicine. After completing fellowships in rheumatology and sports medicine and a Career Development Award from the National Institutes of Health to study exercise for osteoarthritis, Dr. Concoff has developed novel, hybrid approaches to treating musculoskeletal disorders over the course of over 20 years in private practice. He is also a nationally recognized expert in the diagnostic and procedural musculoskeletal ultrasound in rheumatology and sports medicine. For twelve years, Dr. Concoff supervised a renowned wellness center where he developed evidence-driven physical therapy protocols and holistic care paradigms incorporating mind-body approaches, acupuncture, massage therapy, Pilates, yoga and nutritional interventions.

Dr. Concoff is focused on advancing value in the practice of musculoskeletal medicine as Chief Value Medical Officer for United Rheumatology. He has created innovative programs, supported by economic modeling, to evolve specific aspects of clinical care toward better outcomes and lower costs. His programs span the range of musculoskeletal medicine from shoulder and low back pain to osteoarthritis of the knee, as well as a variety of autoimmune diseases.

“The Sports Rheum I” is an introduction to the clinical interface between rheumatology and sports medicine. Several examples are provided to illustrate the rich opportunities provided by this approach. A general description of the pathophysiology of joint damage in osteoarthritis forms the basis for the complementarity of exercise and pharmacologic intervention in osteoarthritis. Two clinical cases are provided to demonstrate the challenges of diagnosing athletes that present with rheumatic disease. An initial introduction to the application of advanced physical therapy techniques to improve strength without antagonizing affected arthritic joints is also provided. Finally, a description of the application of complementary medicine approaches to musculoskeletal disorders is presented.

Each of these examples will be explored in greater depth in subsequent episodes of The Sports Rheum as a part of The Concoff Method from The Rheum Additional series will explore the challenges of practicing medicine during the COVID-19 pandemic, The COVID Rheum, and efforts to evolve musculoskeletal medicine toward better outcomes and lower costs, The Value Rheum.

In today's issue of Rheumatology Network, we introduce The Concoff Method, a new column by Andrew Concoff, M.D., a rheumatologist who serves as executive vice president and chief value medical officer of United Rheumatology. Over the course of the next year, Dr. Concoff will publish columns that address sports medicine, value in rheumatology and managing a medical practice in the era of COVID-19. In this inaugural issue of the column, he covers the interface between sports medicine and rheumatology. 

Introducing the Concoff Method:  The Interface Between Sports Medicine and Rheumatology

Osteoporosis Not Just a Disease of Women

Underdiagnosed and Undertreated

Osteoporosis and COVID-19

In this interview, Jeffrey Curtis, M.D., of the University of Alabama at Birmingham, addresses osteoporosis in men. It's more common than physicians may realize. "It is often misconstrued as a disease that mainly, if not only, effects Caucasian women, which is not the case,” he said.

Treatment Choices:  Rheumatoid Arthritis Case Study

Rheumatoid Arthritis Case Review: 53-year-old Female RA Patient Who Is Biologic Naive

Dr. Christopher Parker, a rheumatologist with The Austin Diagnostic Clinic in Austin, Texas, reviews the following case of a women with rheumatoid arthritis interested in receiving a JAK inhibitor.

Case Study:  53-year-old woman with rheumatoid arthritis

Methotrexate can reduce inflammation and improve function in knees with osteoarthritis, researchers report.

“We should look for inflammation in symptomatic primary knee osteoarthritis patients, and, if found, we should treat it by ant-inflammatory agents,” said Biswadip Ghosh, M.D., an associate professor in the Department of Rheumatology, at the Institute of Post Graduate Medical Education and Research in Kolkata, India.

He presented the finding at the annual meeting of the American College of Rheumatology on Sunday.

Inflammation is a major cause of pain and loss of joint function in patients with primary knee osteoarthritis. There are no widely accepted drug therapies for the condition.

Dr. Ghosh and his colleagues wanted to see if oral methotrexate might help treat this condition, so they recruited 249 patients with radiographic evidence of osteoarthritis and swelling and pain in both joints for at least six months.

This population excluded anyone who had inflammatory arthritis, secondary or advanced osteoarthritis, had undergone arthroscopy, had received intra-articular steroid injections in the preceding three months, or had uncontrolled diabetes, gout, renal diseases, or hepatic diseases.

From this group, they identified 172 patients who had increasing erythrocyte sedimentation (ESR) or c-reactive protein rates. Of these, 137 completed the study.

The researchers randomly assigned 78 of the patients to take 15-20 mg/week of oral methotrexate, and 59 patients to take 1,500 mg/day of glucosamine as a placebo.

To improve study compliance, the researchers allowed patients to take tramadol or acetaminophen for pain and prescribed all patients nonsteroidal anti-inflammatory drugs (NSAIDs) for 7-10 days at the beginning of the study.

After three months, the patients taking methotrexate improved while those taking glucosamine did not.

The erythrocyte sedimentation rate (ESR) of the patients taking methotrexate was 35 versus 43 for the patients taking glucosamine. C-reactive protein (CRP) was non-reactive in the methotrexate group and reactive in the glucosamine group. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score was 38 in the methotrexate group and 43 in the glucosamine group.

Dr. Ghosh advised clinicians to treat inflammation in their osteoarthritis patients. “Methotrexate may be considered in such patients if conventional treatments fail,” he said.

“Comparison of Methotrexate and Glucosamine in Primary Knee Osteoarthritis with Inflammation.” 

The annual meeting of the American College of Rheumatology. 6:00 AM Monday, Nov. 9, 2020.

Methotrexate can reduce inflammation and improve function in knees with osteoarthritis (OA), researchers report.

Methotrexate Reduces Knee Inflammation in Primary Knee Osteoarthritis

How to identify patients with psoriatic arthritis at an earlier stage was a popular theme of research presented at the annual meeting of the American College of Rheumatology on Friday November 6.

More than half of patients with psoriatic arthritis have to wait two or more years for a diagnosis, and time to diagnosis has not significantly improved over the last two decades, a study by Paras Karmacharya, M.D., from the Mayo Clinic, Rochester, Minn., and colleagues found.

Their findings come from an analysis of 162 patients diagnosed with psoriatic arthritis between 2000 and 2017. Median time from joint symptoms to diagnosis by a physician was 2.5 years, with 23% diagnosed at 6 months, 35% at one year and 45% at two years.

Younger patients and those with a higher BMI and enthesitis before diagnosis were more likely to experience a diagnostic delay of more than two years, while patients with sebopsoriasis were less likely to experience diagnostic delay. Radiographic damage may be associated with diagnostic delay, the researchers said, but did not achieve statistical significance in their study perhaps due to the small sample size.

Karmacharya and colleagues study highlights the need to find highlighting the need to find preclinical signs of psoriatic arthritis that will enable providers to identify and treat patients earlier.

Alexis Ogdie-Beatty, M.D., MSCE, of the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and colleagues used administrative claims data on 13,661 patients diagnosed with psoriatic arthritis in an attempt to identify potential predictors of psoriatic arthritis in the six years prior to their diagnosis.

RELATED:  Fewer Than Half of Psoriatic Arthritis Patients Report Obvious Side Effects

Each psoriatic arthritis patient was matched by age, sex, geographic location, insurance, and enrollment duration with two patients who did not have the condition.

Compared with controls, patients with psoriatic arthritis had an increased history of coding for arthritis and skin issues including osteoarthritis (48% vs 22%), rheumatoid arthritis (18% vs 2%), inflammatory polyarthropathy (18% vs 1%), and psoriasis (60% vs 2%). Psoriatic arthritis patients without a prior diagnosis of psoriasis were more likely to have a coding for other forms of arthritis.

Diagnoses of psoriasis, different types of arthritis, axial symptoms, and tendonitis/enthesitis steadily increased as the time of psoriatic arthritis diagnosis drew nearer, along with the frequency of rheumatology visits.

Another retrospective population-based study by Karmacharya and colleagues highlighted that transition from psoriasis to psoriatic arthritis was more likely to be delayed in patients with a family history of psoriasis and severe psoriasis.

The study was based on 157 patients with psoriatic arthritis, 51% of whom had concurrent psoriasis and 49% had psoriasis before a diagnosis of psoriatic arthritis. The researchers found that family history of psoriasis (odds ratio= 2.71; 95% CI 1.24, 5.90) and severe psoriasis (OR=1.96; 95% CI 1.26, 3.06) were more likely in patients who had a delay in transition from psoriasis to psoriatic arthritis than in those who had a concomitant diagnosis.

“Whether this difference is secondary to earlier detection of psoriasis in patients with a family history of psoriasis and severe psoriasis or a true phenotypic difference will require further studies,” the researchers said.

Two further studies used ultrasound to look for early signs of damage that may herald psoriatic arthritis.

In one Sayam Dubash, M.D., and colleagues at the University of Leeds, Leeds Institute for Rheumatic and Musculoskeletal Medicine, NIHR Leeds Biomedical Research Centre and Leeds Teaching Hospitals Trust, in the United Kingdom used ultrasound to show that dactylitis was a clinical indicator for an aggressive phenotype in psoriatic arthritis.

Their study included 177 patients with very early DMARD naïve psoriatic arthritis, of which 81 had dactylitis. Patients with dactylitis recorded significantly higher median differences in tender joint counts (p< 0.01), swollen joint counts (p< 0.001), C-reactive protein (p< 0.01), ultrasound synovitis (p< 0.01), and ultrasound defined erosions (p< 0.01). The metacarpophalangeal 2 and 5 joints were most prone to erosive damage.

“Longitudinal follow-up will determine if dactylitis represents poor prognosis at this very early disease stage,” the researchers said. “Dactylitis may be a useful discriminator for risk stratification in future psoriatic arthritis management strategies.”

In the other Gizem Ayan, M.D., from the division of rheumatology at the University of Ottawa, Canada and colleagues assessed 46 joints and 12 large entheses in 126 patients and showed a link between severity of the joint and entheses involvement.

Greyscale (GS) synovitis score for the joints was moderately correlated with the total enthesitis score (r=0.410, p< 0.001), and the Global Outcome Measure in Rheumatology in Clinical Trials-European League Against Rheumatism Synovitis Score (GLOESS) score also correlated with the total enthesitis score (r=0.400, p< 0.001).

There was a poor correlation between ultrasound assessments and findings on clinical examination, including between swollen joint counts and joint-ultrasound scores (r=0.298, p=0.001 for GLOESS), and between ultrasound entheseal damage scores and tender joint counts (r=0.217, p= 0.018) and swollen joint counts (r=0.326, p= p< 0.001).

The researchers said that their findings support the synovio-entheseal complex theory - that damage to entheses may activate the innate immune system and stimulate rapid development of bursitis.

“Dactylitis Is Associated with Greater Disease Severity, Ultrasound Synovitis, and Erosive Damage, in Very Early DMARD Naïve Psoriatic Arthritis.”

 The annual meeting of the American College of Rheumatology. 9:00 AM, Friday, Nov. 6, 2020.

“The Link Between Joints and Entheses in Psoriatic Arthritis: An Ultrasound Study Supporting the Synovio-entheseal Complex Theory.”

“Delay in Transition from Psoriasis to Psoriatic Arthritis: A Population Based Study.”

 “Diagnostic Delay in Psoriatic Arthritis: A Population Based Study.”

“Longitudinal Analysis of the Patient Pathways to Diagnosis of Psoriatic Arthritis.

More than half of patients with psoriatic arthritis have to wait two or more years for a diagnosis, researchers report.









Early Diagnosis in Psoriatic Arthritis Is Often Missed

The burden and impact on quality of life of treatments for psoriatic arthritis and their failure to provide complete remission are not given enough attention by healthcare providers and greater use of patient reported outcomes measures could be used to highlight these issues and provide treatment targets, according to researchers reporting at the annual meeting of the American College of Rheumatology on Friday November 6.

Two studies presented by Alexis Ogdie-Beatty, M.D., MSCE, from the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, highlighted many of the ongoing issues faced by patients treated for psoriatic arthritis.

“Physicians often consider adverse events when choosing therapies for psoriatic arthritis and rheumatoid arthritis but may give less attention to other ways in which treatments affect the well-being of patients, such as impacts on quality of life, barriers to access, and challenges with taking medications,” she said.

Dr. Ogdie and colleagues looked at patients’ perspectives on the treatment burdens of the most commonly used therapies―methotrexate and TNF inhibitors―through interviews with 24 patients with rheumatoid arthritis and 25 patients with psoriatic arthritis. Nine types of treatment burdens were identified by the patients, who were aged 45-85 years and mostly female side effects, managing side effects, psychological, daily functioning, taking medications, accessing medications, economic impact, work, and family planning/breastfeeding.

RELATED: Long-Term Ixekizumab Versus Adalimumab in Psoriatic Arthritis

Fewer than half of patients reported seeking or receiving medical attention to address side effects, despite the majority of those on methotrexate having to take steps to manage nausea, fatigue, mouth sores, or hair loss which impacted on their quality of life, daily functioning and work. Three-quarters of patients taking TNF inhibitors experienced difficulties accessing, paying for, or taking them.

Discontinuing medication because of lack of effectiveness was more common among patients with psoriatic arthritis than those with rheumatoid arthritis.

It is common for patients with psoriatic arthritis in the United States to fail to achieve remission, and unacceptable symptom states are often accompanied by depression and impaired social interaction, showed another study presented by Dr. Ogdie, which was based on survey data from The National Psoriasis Foundation (NPF).

Data on 801 patients reporting a diagnosis of psoriatic arthritis from a healthcare provider and who had completed the Psoriatic Arthritis Impact of Disease 9 (PsAID-9) revealed that six in ten (59.6%) experienced an unacceptable level of disease activity (PSAID >4). Those with a significant level of unacceptable disease activity were significantly more likely than those with acceptable levels to report depression (2.56 [SD 2.00] vs 0.08 [SD 1.25], p≤.0010 and inability to participate in social activities (mean T-scores 44.56 [SD 6.83] vs 55.46 [SD 6.99], p≤.001).

Greater awareness of treatment burdens experienced by patients with psoriatic arthritis, which were rarely addressed in clinical trials or observational studies, might help healthcare providers better support patients with any medication-related challenges that they encountered, Dr. Ogdie said.

Several different composite instruments can be used to define low disease activity and remission targets for treatment in patients with psoriatic arthritis, but another study highlighted that many patient-reported outcomes (PROs) correlate well with these measures so could also be used.

Using composite indices as the reference standards, the research team which included Dr. Ogdie, compared the performance of various patient-reported outcomes measures, including Patient-Reported Outcomes Measurement Information System (PROMIS) instruments, EULAR Psoriatic Arthritis Impact of Disease (PSAID12), and Routine Assessment of Patient Index Data 3 (RAPID3), in 227 patients.

Compared to patients with low disease activity patients in remission had significantly more favorable PROMIS Physical, PROMIS Mental, PROMIS Fatigue, and PSAID12 scores, and correlations with the composite indices were strong for PROMIS GH physical health (r=0.65- 0.69) and PSAID12 (r=-0.77- 0.79).

Use of patient reported outcomes to measure low states of disease activity should be considered for additional treatment targets in psoriatic arthritis, said Juliette Yedimenko from the Cleveland Clinic, Cleveland, who presented the findings. “RAPID3 Near-Remission may be the most rigorous PRO criteria (including only the lowest states of disease activity), while PSAID Patient Acceptable State may identify a broader range of low states of disease activity,” she added.

“Perspectives on Treatment Burden for Methotrexate and TNF-inhibitors Among Psoriatic Arthritis and Rheumatoid Arthritis Patients: A Qualitative Study.” The annual meeting of the American College of Rheumatology. 9:00 AM, Friday, Nov. 6, 2020.

“Prevalence and Impact of Unacceptable Symptom State Among Patients with Psoriatic Arthritis: Results from the National Psoriasis Foundation’s 2019 Annual Survey.” The annual meeting of the American College of Rheumatology. 9:00 AM, Friday, Nov. 6, 2020.

 “Patient-Reported Outcomes Differentiate Between Remission and Low Disease Activity in Psoriatic Arthritis.” The annual meeting of the American College of Rheumatology. 9:00 AM, Friday, Nov. 6, 2020.

Many patients with psoriatic arthritis live with unacceptable levels of disease activity despite treatment, and patient-reported outcomes could provide useful treatment targets, shows a new study.

One Step Closer to Precision Medicine in RA

Early RA Treatment Can Stave Off Heart Disease

Lupus Patient Perspectives: Self Advocacy

Stress Can Take Its Toll Rheumatic Disease

Introducing the Concoff Method: The Interface Between Sports Medicine and Rheumatology

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Rheumatoid Arthritis Case Study