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 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).68
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.69
Updated recommendations advise that treatment selection for psoriatic arthritis should take into account the different active disease domains and the presence of comorbidities. Therapies in psoriatic arthritis should target as many active disease domains as possible.
Historically, conventional disease-modifying antirheumatic drugs (cDMARDs) have been used to treat psoriatic arthritis based on efficacy in treating joint disease in rheumatoid arthritis, and for cutaneous psoriasis.70 However, there are conflicting data on the benefits of cDMARDs in treating some domains of psoriatic arthritis, such as enthesitis.21,71
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, to optimise patient benefit.68 The recommendations suggest targeting as many active disease domains as possible and considering a patient’s prior treatment history and comorbidities.68
The therapeutic recommendations differ between disease domains. For example, cDMARDs are not recommended for the treatment of patients with enthesitis.68
The objective of the Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) study was to investigate physicians’ perspectives on the effect of psoriasis and psoriatic arthritis on patients’ daily lives, and of patients’ satisfaction with treatments and medical care.72,73
The study findings suggested a mismatch between patient perceptions and treatment goals, with concerns among participating physicians and patients about the use of conventional treatments to treat psoriasis or psoriatic arthritis. Tolerability issues were the most common patient concerns regarding the use of cDMARDs (78%)72 and the most common reason for rheumatologists not initiating cDMARDs therapy (30%).72
Long-term safety, patient contraindications, side effects, patient lifestyle modifications and loss or reduction of efficacy with the use of cDMARD therapy were also areas of concern for physicians and patients.72,73
The MAPP survey revealed that 57% of the psoriasis and psoriatic arthritis patients who had been prescribed a cDMARD discontinued treatment. This was most often due to safety and tolerability issues (45%), and/or lack of efficacy (30%).73
Further research has identified concerns around pre-screening and ongoing monitoring requirements, as well as multiple cautions associated with the use of cDMARDs, for example in patients with fatty liver disease, a comorbidity associated with psoriatic arthritis. Research concludes that alternative treatment options are important to help patients for whom cDMARDs therapy is ineffective or unsuitable.74
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