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
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
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
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.
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
Fig. 11: Scores validated for use in psoriatic arthritis
1. Kavanaugh A, et al. Rheumatol Ther 2016;3:91–102
2. Kyriakou A, et al. Sci World J 2014; Article ID 508178;
3. Lee E, et al. J Exp Med 2004;199:125–30;
4. Lowes M, et al. J Invest Dermatol 2008;128:1207–11
5. Yao Y, et al. PLoS One 2008;3:e2737
6. Taylan A, et al. Rheumatol Int 2012;32:2511
7. Limon-Camacho L, et al. J Rheumatol 2012;39:830–5.
8. Van Kuijk A and Tak P. Curr Rheumatol Rep 2011;13:353–9
9. Ritchlin C, et al. J Rheumatol 1998;25:1544–52
10. Menon B, et al. Arthritis Rheumatol 2014;66:1272–81
11. Celis R, et al. Arthritis Res Ther 2012;14:R93
12. Spadaro A, et al. Ann Rheum Dis 2002;6:174–6
13. Molteni S and Reali E. Psoriasis: Targets and Therapy 2012;2:55–66
14. Siegel E, et al. Curr Opin Rheumatol 2015;27:111–7
15. Lories R, et al. Nat Med 2012;18:1018–9
16. Ebihara S, et al. Autoimmunity 2015;29:1–8
17. Ruutu M, et al. Arthritis Rheum 2012;64;2211–22
18. Sherlock J, et al. Nat Med 2012;18:1069–77
19. Yamamoto M, et al. J Invest Dermatol 2015;135:445–53
20. Reinhardt A, et al. Arthritis Rheumatol 2016;68:2476–86
21. Coates LC, et al. Lancet 2015;386:2489–98.
22. Mease PJ, et al. Drugs 2014;74:423–41.
23. Schafer P. Biochem Pharmacol 2012;83:1583–90.
24. Van Kuijk A and Tak P. Curr Rheumatol Rep 2011;13:353–9
25. Ritchlin C, et al. J Rheumatol 1998;25:1544–5226. Menon B, et al. Arthritis Rheumatol 2014;66:1272–81
27. Celis R, et al. Arthritis Res Ther 2012;14:R93
28. Spadaro A, et al. Ann Rheum Dis 2002;6:174–6
29. Molteni S and Reali E. Psoriasis: Targets and Therapy 2012;2:55–66
30. Siegel E, et al. Curr Opin Rheumatol 2015;27:111–7
31. Lories R, et al. Nat Med 2012;18:1018–9
32. Ebihara S, et al. Autoimmunity 2015;29:1–8
33. Ruutu M, et al. Arthritis Rheum 2012;64;2211–22
34. Sherlock J, et al. Nat Med 2012;18:1069–77
35. Yamamoto M, et al. J Invest Dermatol 2015;135:445–53.
36. Reinhardt A, et al. Arthritis Rheumatol 2016;68:2476–86
37. Taylan A, et al. Rheumatol Int 2012;32:2511
38. Limon-Camacho L,et al. J Rheumatol 2012;39:830–5.
39. Lee E, et al. J Exp Med 2004;199:125–30
40. Lowes M, et al. J Invest Dermatol 2008;128:1207–11
41. Yao Y, et al. PLoS One 2008;3:e2737
42. Kyriakou A, et al. Sci World J 2014;Article ID 508178.
43. Gottlieb A, et al. J Am Acad Dermatol 2008;58:851–64.
44. Scutellari P, et al. Eur J Radiol 1998;27(suppl 1):S31–38.
45. Coates LC, et al. Arthritis Rheumatol 2016;68:1060–71.
46. Moll JMH and Wright V. Semin Arthritis Rheum 1973;3:55–78.
47. Helliwell PS. Clin Rheum 2015;33:S44-47
48. McGonagle D, et al. Lancet 1998;352:1137–40.
49. McGonagle D & McDermott MF. PLoS Med 2006;3:e29.50. Schett G, et al. Nat Rev Rheumatol 2017;13:731–41.
51. Ritchlin CT, et al. N Engl J Med 2017;376:957–70
52. Ravindran J, et al. Arthritis Care Res 2010;62:86–91.
53. Gladman DD, et al. Arthritis Rheum 2007;56:476–88.
54. Kavanaugh A, et al. Arthritis Rheum 2012;64:2504–17.
55. Kavanaugh A, et al. Ann Rheum Dis 2014;73:1020–6
56. van der Heijde D, et al. Arthritis Rheum 2016;68:1914–21
57. Strand V & Sharp JT. Arthritis Rheum 2003;48:21–34.
58. van der Heijde, et al. Ann Rheum Dis 2005; 64(Suppl II):ii61–4.
59. Husted JA, et al. Arthritis Care Res (Hoboken) 2011;63:1729–35
60. Husted JA, et al. J Rheumatol 2013;40:1349–56.
61. Edson-Heredia E, et al. J Eur Acad Dermatol Venereol 2015;29:955–63.
62. Ogdie A, et al. J Rheumatol 2014;41:2315–22.
63. Ogdie A, et al. J Invest Dermatol 2017 [Epub]
64. Wervers K, et al. J Rheumatol 2018;45:1526–31
65. Nossent J & Gran JT. Scand J Rheumatol 2009;38:251–5
66. Coates L, et al. Arthritis Rheum 2013;65:1504–9
67. Lindqvist U, et al. J Rheum 2008;35:668–73
68. Husni M. Rheum Dis Clin N Am 2015;41:677–698
69. Queiro-Silva R, et al. Ann Rheum Dis 2003;62:68–70
70. Singh J et al. Arth care res 2019;71:5–32
71. Kavanaugh A, et al. Rheumatol Ther 2016;3:91–102
72. van Mens L, et al. Rheumatology (Oxford) 2018;57:283–90
73. van Mens L, et al. Ann Rheum Dis 2017;77:251–7
74. Huscher D, et al. ACR 2015: Abstract 679
75. Veale DJ & Fearon U. RMD Open 2015;1:e000025 77. Wilsdon TD, et al. Cochrane Database Syst Rev 2017, Art. No.: CD012722
76. Dures E, et al. Patient 2017;10:455–62 78. Xu U, et al. Am Health Drug Benefits 2018;11:408–17
79. Lebwohl M, et al. J Am Acad Dermatol 2014;70:871–81
80. van de Kerkhof P, et al. J Eur Acad Dermatol Venereol 2015;29:2001–210
81. Gossec L, et al. Ann Rheum Dis 2014;73:1012–19
82. Lubrano E, et al. Clin Exp Rheumatol
2015;33(5 Suppl 93):S51–4
83. FitzGerald O, et al. Ann Rheum Dis 2012;71:358–62
84. Waxman R & Helliwell P. Ann Rheum Dis 2018;77:467–8