Treating psoriatic arthritis: Advances in our understanding
Professor Pascal Richette, Dr Frank Behrens and Professor Oliver FitzGerald share their perspective on the importance of tailoring your treatment approach to consider all six domains of psoriatic arthritis and individual patient needs.
Advances in the understanding of psoriatic arthritis pathophysiology, comorbidities, patient perspective and experience, and assessment measures, in addition to the development of new targeted therapies, have led to the updating of treatment recommendations, such as the GRAPPA recommendations (see Additional Resources).45
New targeted drug treatments have demonstrated different results in psoriatic arthritis and rheumatoid arthritis patients, suggesting the diseases have distinct underlying mechanisms and require different treatment approaches.75
Updated recommendations advise that treatment selection for psoriatic arthritis should take into account:76,77,78
- Active disease domains
- The presence of comorbidities
- Patient-reported outcomes (PROs)
- Individual preferences
Therapies in psoriatic arthritis should target as many active disease domains as possible.
Historically, conventional disease-modifying antirheumatic drugs (csDMARDs) have been used to treat psoriatic arthritis based on efficacy in treating joint disease in rheumatoid arthritis, and for cutaneous psoriasis.77 However, studies have shown around 35% of patients have residual disease activity when treated with csDMARDs, and in most cases their treatment is not adjusted despite alternatives being available to them.45,72
Ideally, patients should be reviewed promptly and evaluated regularly to ensure they receive the treatment adjustments that might be needed to achieve their individual goal.45
GRAPPA recommendations
The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) advocate a tailored treatment approach for patients with psoriatic arthritis based on domain involvement and patient-reported outcomes, to optimise patient benefit. The GRAPPA treatment goal in psoriatic arthritis is to achieve the lowest possible level of disease activity in all domains of the disease.45
The recommendations suggest targeting as many active disease domains as possible and considering a patient’s prior treatment history and comorbidities.45
The therapeutic recommendations differ between disease domains. For example, csDMARDs are not recommended for the treatment of patients with enthesitis.45
See the full grappa Treatment Recommendations HERE45
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GRAPPA treatment recommendations45
Taking patient perspective into consideration when treating moderate psoriatic arthritis
GRAPPA guidelines recommend considering patient perspective when coming to a therapeutic decision.78 Studies show that patients and physicians may have different perspectives on disease states, therefore it is important to discuss QoL with patients to gain an accurate reflection of individual patient needs.79,80
In addition to the efficacy of treatment, minimising any harm or burden of treatment is particularly important to patients. It encompasses concerns about the long-term effects of treatment, mode of administration and requirements for laboratory monitoring.76,78
The Multinational Assessment of Psoriatic Arthritis (MAPP) study, investigated physicians’ perspectives on the effect of psoriasis and psoriatic arthritis on patients’ daily lives, as well as patients’ satisfaction with treatments and medical care. The study found a mismatch between patient perceptions and treatment goals.79,80
In this study, tolerability issues were the most common patient concerns regarding the use of csDMARDs (78%). Long-term safety, patient contraindications, side effects, patient lifestyle modifications and loss or reduction of efficacy with the use of csDMARDs therapy were also areas of concern for physicians and patients.79,80
Further research has identified concerns around pre-screening and ongoing monitoring requirements, as well as multiple cautions associated with the use of csDMARDs, for example in patients with fatty liver disease, a comorbidity associated with psoriatic arthritis.78
It is therefore important for the physician and patient to speak openly about patient preferences and values for better treatment selection and outcomes.76,78,81
Professor Pascal Richette and Dr William Tillett share their perspective on why a patient-focused approach is important when considering treatment options.
Overview of validated scores for use in psoriatic arthritis
There are various scores that have been validated which all define psoriatic arthritis disease activity.73 Each comes with their own set of benefits and limitations and are reflective of providing treatment goals that are in line with international guidelines. Benefits can range from reflecting the multidimensional nature of psoriatic arthritis to helping drive tailored treatment choice, while limitations may include their feasibility and complexity of use in clinical practice (see Figure 11).73, 82—84
Scores validated for use in psoriatic arthritis73, 82—84
Disease Activity index for Psoriatic Arthritis (DAPSA) & clinical DAPSA (cDAPSA)
Minimal Disease Activity (MDA) & Very Low Disease Area (VLDA)
Psoriatic Arthritis Disease Activity Score (PASDAS)
Composite Psoriatic Disease Activity Index (CPDAI)
Fig. 11: Scores validated for use in psoriatic arthritis
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