The 2015 recommendations for PsA treatment highlight the importance of managing comorbidities and a patient-centered treatment approach.
The 2015 recommendations for the treatment of psoriatic arthritis highlight the importance of managing comorbidities and they rely heavily on a patient-centered treatment approach.
The recommendations, published in March in the journal Arthritis & Rheumatology, were developed by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA). GRAPPA last released recommendations in 2009, and the 2015 update includes input from patient partners, said Christopher Ritchlin, M.D., Ph.D., a rheumatologist at the University of Rochester Medical Center and co-chair of the GRAPPA Treatment Recommendations Committee.
“There have been major therapeutic developments in a number of different areas since 2009. So, we revisited the basic principles of therapy and for the first time, introduce the importance of comorbidities for diagnosis and treatment,” Dr. Ritchlin said.
Comorbidities are just one reason that psoriatic arthritis is difficult to treat; there is also a dearth of high-quality clinical trials on traditional treatments. But GRAPPA's recommendations are based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method, which involves taking into account the strength of research and measuring consensus among experts when determining recommendations. Another key feature is "the grid," a way of visualizing both the domains involved in the disease and the severity of symptoms. The group is also working on adding information to the GRAPPA website to demonstrate how to use the recommendations in actual patient scenarios.
In this Q&A with Rheumatology Network, Dr. Ritchlin addresses specific aspects of the 2016 treatment recommendations.
Rheumatology Network: The 2016 recommendations include the five domains of psoriatic arthritis, why is that important?
Dr. Ritchlin: It's been our contention - and I think it's become mainstream now - that in order to effectively diagnose and treat a patient with psoriatic arthritis, you have to take all these domains into account. So, we evaluated the literature for the five PsA domains: skin, peripheral, the axial disease, dactylitis and enthesitis.
The recommendations include a grid, which has the five domains and a severity component, which is based on the evidence at that time. With this grid we try to introduce clinicians to how they might use these recommendations to help make a diagnosis.
Rheumatology Network: What new therapies have been approved for PsA since 2009?
Dr. Ritchlin: The five domains now include ustekinumab, secukinumab and apremilast, which were all introduced since the last recommendations.
Rheumatology Network: The recommendations include a section specifically on comorbidities, why is that essential?
Dr. Ritchlin: PsA patients represent a group with a high degree of comorbidities from uveitis to obesity - which is a major problem for these patients and should be addressed because if it is not, the likelihood of long-lasting remission goes down. Other common comorbidities include type II diabetes, metabolic syndrome, inflammatory bowel disease, hypertension, fatty liver, anxiety and depression.
The comorbidity section in the paper addresses evaluating patients who present with specific comorbidities and how to treat them.
Rheumatology Network: What influence did the patient partners bring to the process?
Dr. Ritchlin: Each of the five domains included input from patients who would tell us what worked for them and what didn’t work, which helped frame the treatment recommendations. Just throwing a bunch of biologic medications at patients may not get them where they want to be. The key is engaging the patient in the process so that they're involved.
Rheumatology Network: Are there any misconceptions or myths about psoriatic arthritis management that you'd like to clear up?
Dr. Ritchlin: I think the challenge with psoriatic arthritis is you have so many different areas with involvement that adherence to a complex medical regimen is low. If you have patients who are slathering on topicals and taking a bunch of pills a couple times a day, maybe getting some UV light, adherence is going to be problematic. It's just too much for patients to follow on a regular basis.
The key element is to carefully evaluate the patient at baseline, sort out the major issues for them, in terms of domains and comorbidities, and then develop a treatment plan that is as simple as can be and has the patient addressing some of the key comorbidities.
Coates LC, Kavanaugh A, Mease PJ, et al. “Group for Research and Assessment of Psoriasis and Psoriatic Arthritis 2015 Treatment Recommendations for Psoriatic Arthritis.” Arthritis & Rheumatology. March 23, 2016. doi:10.1002/art.39573.
Ritchlin CT, Kavanaugh A, Gladman DD, et al. “Treatment recommendations for psoriatic arthritis,” September 2009. Annals of the Rheumatic Diseases. doi:10.1136/ard.2008.094946.