Low Progression of Erosive Disease with T2T in Early PsA

July 3, 2014

Targeted treatment for psoriatic arthritis, already shown to improve disease activity markers, now associated with low rates of progression in joint erosion.

Coates LC, Helliwell PS. Low level of erosive change is found in early psoriatic arthritis. EULAR Abstract SAT0406. June 13, 2014. DOI: 10.1136/annrheumdis-2014-eular.2907 

Coates, L, Moverley AR, McParland L, et al., Results Of a Randomised Controlled Trial Comparing Tight Control Of Early Psoriatic Arthritis (TICOPA) With Standard Care: Tight Control Improves Outcome. American College of Rheumatology (ACR) 2013, Abstract 814. Arthritis Rheum 2013;65 Suppl 10 :814 DOI: 10.1002/art.2013.65.issue-s10.

Recent updates from the ongoing Tight Control Of Early Psoriatic Arthritis (TICOPA) trial in Britain show that tight control as a treat-to-target (T2T) strategy significantly improves both joint and skin outcomes for newly-diagnosed PsA patients, compared to standard therapy.

The latest TICOPA data, reported at the European League Against Rheumatism (EULAR) meeting in Paris, finds little progression of erosive disease during active therapy, most of it among older PsA patients.

Earlier data show that PsA patients are also more likely to achieve minimal disease activity with low radiographic progression and no unexpected serious adverse events.

These findings reinforce EULAR’s 2012 PsA management recommendations, [http://ard.bmj.com/content/71/1/4.long]which say “modern therapy of PsA should be target-oriented” with remission, or at least low or minimal disease activity, as a goal.

The 206 patients in the multi-center TICOPA cohort (52% males, median age 45) were recruited between 2008 and 2012 and randomized to a T2T regimen or standard care (no set regimen). X-rays of the hands and feet were taken at baseline and at 48 weeks; 71% had polyarticular arthritis.

A majority of patients received standard disease modifying anti-rheumatic drugs (DMARDs), but after a year 23.4 % were on anti-tumor necrosis (TNF) drugs.

The TICOPA T2T arm followed a strict protocol with dose escalation if patients had not met minimal disease activity targets (20%, 50%, or 70% improvement by the American College of Rheumatology’s ACR20/ACR50/ACR70 criteria) by 48 weeks.

T2T patients were started on methotrexate (MTX) with rapid dose escalation and progression to combination DMARD therapy if they had not reached ACR20 within 12 weeks. After another 12 weeks, patients who still had three or more tender and swollen joints were put on anti-TNF therapy or an alternative DMARD in combination with MTX.

Most patients who finished the trial (n=176) had shown little joint erosion on X-rays (the median Sharp van der Heijde score was zero) at baseline. Some did start out with erosive disease, but their number increased only slightly (24.5% to 30.1%) by 48 weeks.

Those patients tended to be older and to have polyarticular disease and elevated C-reactive protein, but these associations were not significant. Erosions (with joint space narrowing) were mostly seen in the hands.

TICOPA data from the same cohort presented in October 2013 at the ACR annual meeting showed that 62% of T2T patients achieved ACR20 at 48 weeks, compared to 44.6% of the standard care group.

More T2T patients achieved ACR50 and ACR70 in that period, as well. Patients reported some minor adverse events (AEs), including nausea and infections (e.g. common cold), but there were few serious AEs.