Striking the Right Balance in Psoriatic Arthritis Care

Treat to target (Tiero,AdobeStock_83756673)

Treat-to-target (T2T) strategies can be effective in addressing rheumatic diseases like psoriatic arthritis (PsA), but may not be enough on their own to single-handedly improve quality of life for those living with the disease.

That was the conclusion of a recent analysis conducted by psoriatic arthritis researchers, who recommended supplemental strategies to help better manage psoriatic arthritis and similar conditions over time.

In an interview with Rheumatology Network, report co-author Maarten de Wit, Ph.D., a rheumatology researcher at Utrecht University in The Netherlands who also lives with psoriatic arthritis, said, “Our question was: Is a treat-to-target strategy the holy grail we hoped for? We support the proposal to treat rheumatic diseases to two targets: biological remission and remission from the patient’s perspective. This has recently been coined as a dual-target strategy.”

The authors of the article, which was first published Aug. 2 in Arthritis and Rheumatology, wrote that while treat-to-target can lower disease activity and increase function, it does not always lead to better patient-reported outcomes of symptoms that are important to patients like pain or fatigue.

The two authors, which included Casper G. Schoemaker, Ph.D., highlighted several studies that explored the effects of treat-to-target on patient-centered measures in patients with rheumatic diseases. These tools can be helpful, study authors contended. The authors wrote that the PsA Impact of Disease questionnaire was a good example of such tools, as it allows clinicians to assess 12 different disease domains individually.

However, in one study cited by the authors, 43 percent of patients who followed treat-to-target strategies continued to experience fatigue even after their disease activity scores went down.

“There is a substantial number of PsA patients who are in remission but still have symptoms, which deserve the attention of health professionals but in practice are often neglected,” Dr. de Wit said. “To measure the success of a T2T strategy, a disease activity score will not suffice.”

Improving quality of life in these patients means a greater focus on understanding and addressing patient-centered goals, study authors concluded. Rheumatology caregivers should consider options alongside treat-to-target, such as exercise, specialized surgery, or psychosocial support, as part of a dual-target approach.

Given its notoriously varied effects, this concept is particularly relevant for psoriatic arthritis, Dr. de Wit said. He compared the dual-target approach to the goal of a perfect strike in a game of bowling.

“The bowling ball will never directly knock down all 10 pins. Therefore, bowlers aim at the so-called ‘head pin’ in the front, which is knocked down directly by ball impact and starts a cascade effect by which pins interact with and knock each other down,” he said.

A more holistic approach—or a full ‘pin count’—must occur in order to address all aspects of psoriatic arthritis and provide comprehensive care for people living with the disease. The authors called for trajectory analyses to understand the associations among treat-to-target and patient-reported outcomes.

“Rheumatologists should, together with the patient, look beyond the target of remission. They should be more ambitious and work toward the ultimate goal of bringing patients back to normal. To further the bowling metaphor, that requires health professionals and patients to define which ‘pins’ are important to achieving full remission for that patient and not lay back when only the first three or four pins are hit. It is the transition from treating a disease to managing a condition,” Dr. de Wit said.

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REFERENCE

Schoemaker CG and De Wit MPT. Treat to target from the patient perspective is bowling for a perfect strike. Arthritis & Rheumatology. 2020; online. Published 2020 Aug 2. doi:10.1002/art.41461