Sustained Very Low Disease Activity and Remission in Psoriatic Arthritis Patients

Residual Disease Activity in Canadian Patients With Psoriatic Arthritis Treated With Advanced Therapies: Results From a Multiregistry Analysis (UNISON-PsA)

OBJECTIVE

Although patient outcomes in psoriatic arthritis (PsA) have improved with the advent of advanced therapies, there remains a high unmet need to treat residual disease activity. The objective of the current study was to quantify residual disease activity and burden of disease in Canadian patients with PsA.

METHODS

This was a multiregion, observational, retrospective analysis of patient data extracted from the Rhumadata and the International Psoriasis and Arthritis Research Team (IPART) registries, analyzing deidentified data from patients who had initiated advanced therapy for the treatment of PsA between January 2010 and December 2019. The primary endpoint was the proportion of patients failing to achieve minimal disease activity (MDA) within 6 months; secondary endpoints included clinical and patient-reported burden of disease. Descriptive statistics included summaries by region, treatment class, and number of prior advanced therapies.

RESULTS

One thousand five hundred ninety-six patients were included. The proportions of patients who failed to achieve MDA within 6 months of an advanced therapy were 64.8% in Ontario, 68.3% in Western Canada, 74.8% in Quebec, and 75% in the Atlantic/East region. Failure to achieve MDA was higher among patients receiving an IL-17i compared with a TNFi in all regions except the Atlantic/East. Between 73.2% and 78.6% of patients reported pain at 6 months, and continuing functional impairment varied from 24% in the West to 83.3% in the Atlantic/East.

CONCLUSION

There is substantial burden and unmet need for improved therapies for Canadians with PsA. There is a wide regional variation in outcomes that requires further assessment.

Psoriatic arthritis: improvement in outcomes but persistent sex difference - 5-year follow-up study of a Norwegian outpatient clinic population

OBJECTIVE

This study aimed to explore long-term changes in disease activity and remission rates, and potential sex-related differences in these outcomes, in psoriatic arthritis (PsA) patients treated in an outpatient clinic.

METHOD

This prospective longitudinal cohort study included 114 patients. The Disease Activity Index for Psoriatic Arthritis (DAPSA), clinical DAPSA (cDAPSA), 28-joint Disease Activity Score (DAS28), Simplified and Clinical Disease Activity Indices (SDAI, CDAI), Boolean remission for PsA, and minimal and very low disease activities (MDA, VLDA) were assessed. For group characteristics, parametric statistics and linear regression were used.

RESULTS

At 5 year follow-up, improvement was noted for multiple measures reflecting disease activity and patient-reported outcomes. Statistically significant increases in remission rates were observed using DAS28 (+21.2%), CDAI (+9.7%), and cDAPSA (+7.6%), but not SDAI, DAPSA, Boolean remission, MDA, or VLDA. During the study period, the proportion of patients treated with biological disease-modifying anti-rheumatic drugs (bDMARDs) increased from 37.7% to 48.3% (p = 0.007). At baseline, women reported higher pain and fatigue, and had higher tender joint counts, DAPSA, cDAPSA, SDAI, CDAI, and DAS28 than men. Despite higher mean baseline C-reactive protein, men more often achieved remission, regardless of the definition applied. A higher proportion of men than women was treated with bDMARDs (baseline: 46.6% vs 28.6%; follow-up: 58.6% vs 33.9%).

CONCLUSION

This study adds evidence supporting recent improvements in PsA outcomes. Women had higher disease activity and were less likely to achieve remission than men. Despite progress in achieving remission goals, there is still room for improvement in therapeutic approaches for PsA patients.

Identification of the Minimal Disease Activity Domains Achieved Based on Different Treatments in Psoriatic Arthritis

INTRODUCTION

The aim of this work is to characterize which Minimal Disease Activity (MDA) domains are mainly achieved, based on different treatments, in psoriatic arthritis (PsA) patients. Moreover, the association between MDA achievement and the different treatment groups was assessed.

METHODS

We conducted a cross-sectional analysis of two longitudinal PsA groups. Inclusion criteria were: age ≥ 18 years, PsA diagnosis, stable treatment for at least 6 months. Patients were grouped depending on the therapy: group 1: Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)/cyclooxygenase 2 inhibitors (COX2i)/steroids, group 2: conventional synthetic Disease-Modifying Anti-Rheumatic Drugs (csDMARDs), group 3: Tumor Necrosis Factor α  inhibitors (TNFi), group 4: interleukin inhibitors (IL)12-23i or IL-23i, group 5: IL-17i, group 6: phosphodiesterase 4 inhibitors (PD4i). For each group, the achieved domains based on therapy were assessed. Multivariate logistic regression analysis was performed to assess the association between the treatment groups and the MDA achievement.

RESULTS

A total of 220 patients were enrolled, and MDA was achieved in 45.8% of them. In all treatment groups, the first MDA domains achieved were: body surface area ≤ 3, swollen joint count ≤ 1 and Leeds Enthesitis Index ≤ 1, while MDA domains less frequently achieved were Patient Global Assessment (PtgA) ≤ 2 cm and pain on visual analogue scale ≤ 1.5 cm. The logistic regression analysis showed higher odds ratios for the achievement of the MDA in those patients in groups 3 and 4.

CONCLUSIONS

In each treatment group, MDA domains less frequently achieved were PtGA and pain, suggesting that "patient-driven domains" are still an unmet need. Due to the study design and the low number of patients in some groups, it is not possible to clearly define which MDA domain was achieved or not based on treatment; however, it seems that some differences could be present. If larger and prospective studies confirm our preliminary results, we could move toward a personalized/domain treatment approach in PsA.

Treat-to-target in real-life psoriatic arthritis patients: achieving minimal disease activity with bDMARDs/tsDMARDs and potential barriers

OBJECTIVE

(1) to describe the frequency of minimal disease activity (MDA) in a real-life psoriatic arthritis (PsA) cohort, (2) to longitudinally explore predictors of MDA; (3) to examine frequency and predictors of low disease activity (LDA) in patients with axial involvement (axPsA).

METHODS

consecutive PsA patients in stable biological/targeted-synthetic Disease-Modifying Anti-Rheumatic Drugs (bDMARDs/tDMARDs) who attended our center were enrolled. Disease activity indices, including MDA and ankylosing spondylitis disease activity score-LDA (ASDAS-LDA) for axPsA, were evaluated at baseline and every 6 months, up to 36 months or bDMARDs/tsDMARDs discontinuation. Patients' history, BMI, comorbidities - including osteoarthritis (OA) and fibromyalgia - were collected. Variables were compared between patients who achieved sustained MDA and those who did not. Multivariable generalized estimating equation (GEE) models were built to identify predictors of MDA and ASDAS-LDA over time. Data were expressed as beta coefficient (95%CI).

RESULTS

104 patients were enrolled, 54% males, mean age 55.7 years; 52% had axPsA. Across all evaluations, 52-61% reached MDA, and 17-24% achieved ASDAS-LDA. AxPsA, fibromyalgia, OA and BMI≥35 were less frequently observed in patients with sustained MDA. The GEE model confirmed the following factors were significantly and independently associated with MDA: age (Beta=-0.05), bDMARDs/tsDMARDs duration (Beta=+0.31), axPsA (Beta=-1.07), fibromyalgia (Beta=-3.35), OA (Beta=-1.87), BMI≥35 (Beta=-2.53). Age (Beta=-0.01), fibromyalgia (Beta=-2.03) and OA (Beta=-1.30) were also independently associated with ASDAS-LDA.

CONCLUSIONS

MDA is an attainable target in real-life. AxPsA represents a difficult-to-treat subset. Sustained MDA depends on disease features (axPsA) as well as patients' characteristics (e.g. age, bDMARDs/tDMARDs duration, comorbidities).

Evaluation of clinical efficacy of tumor necrosis factor‑α inhibitors in treatment of distal extremity swelling with pitting edema in psoriatic arthritis of inadequate response to conventional therapy: A 10‑year retrospective study

Distal extremity swelling with pitting edema in psoriatic arthritis (PsA) is a rare rheumatological condition, whose management presents a challenge. The aim of the present study was to identify the clinical characteristics of, and formulate a standardized management strategy for, patients with distal extremity swelling with pitting edema in PsA. The medical records of consecutive patients with PsA, with or without distal extremity swelling with pitting edema, were systematically analyzed over a ~10-year period (between September 2008 and September 2018) in a single center and a comprehensive review (pathogenic mechanisms, clinical manifestations, and treatments) was undertaken. A total of 167 patients with PsA were evaluated, and distal extremity swelling with pitting edema was recorded in 16 of these patients. In three of the 16 patients, distal extremity swelling with pitting edema occurred as the first, isolated manifestation of PsA. The upper and lower extremities were affected, predominantly asymmetrically. Female patients with PsA were more likely to be affected with pitting edema and the blood test results revealed that the patients with PsA and pitting edema also presented with a significantly higher erythrocyte sedimentation rate and concentration of C-reactive protein. The onset of pitting edema was associated with the activity of the disease. Lymphoscintigraphy and magnetic resonance imaging (MRI) scans revealed that edema might have resulted from inflammation of the tenosynovial structures. Furthermore, treatment with tumor necrosis factor-α inhibitor (TNFi) elicited improvements in patients with pitting edema that were not responsive to conventional synthetic disease-modifying antirheumatic drug therapy. In conclusion, distal extremity swelling with pitting edema, also termed atypical remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome, may represent the initial isolated manifestation of PsA. The atypical RS3PE syndrome in PsA was attributable to inflammation of the tenosynovial structures, and TNFi may serve as a potential treatment.

Disease control in patients with psoriatic arthritis in real clinical practice in Spain: MiDAS study

OBJECTIVE

MiDAS study assessed the percentage of psoriatic arthritis (PsA) patients treated in routine clinical practice who achieved control of disease activity according to Disease Activity in Psoriatic Arthritis (DAPSA) and Minimal Disease Activity (MDA).

METHODS

Observational, non-interventional, cross-sectional, multicenter study conducted under conditions of routine clinical practice in 36 centers with outpatient rheumatology clinics in Spanish public hospitals. Patients included were adults (≥18 years) with ≥6 months PsA diagnosis according to classification for PsA (CASPAR) criteria and undergoing treatment ≥3 months. The main variable evaluated was the percentage of patients under remission and low disease activity, assessed through DAPSA and MDA.

RESULTS

313 patients with PsA were included: 54.3% male; with mean age of 54.1±12.2 years and mean disease duration of 10.5±9.0 years. Mean C-reactive protein (CRP) serum levels were 4.9±7.3mg/L. At the study visit, 58.5% of patients were in monotherapy (17.6% biological and 40.9% non-biological) and 41.2% were receiving biological and non-biological therapy. 59.4% of patients showed low disease activity (DAPSA≤14) and 19.8% were on remission (DAPSA≤4). Moreover, 51.4% of the patients reached an MDA status (≥5 MDA).

CONCLUSIONS

Around 40% of PsA patients presented uncontrolled disease, highlighting the need to improve the management of these patients in clinical practice.

Impact of Physician-Defined Flares on Quality of Life and Work Impairment: An International Survey of 2238 Patients With Psoriatic Arthritis

OBJECTIVE

To describe psoriatic arthritis (PsA) flares and their effect on patient-reported outcomes (PROs).

METHODS

Cross-sectional surveys of rheumatologists/dermatologists and their patients with PsA were conducted in France, Germany, Italy, Spain, the United Kingdom, and the United States, capturing data on physician-reported patient flare status, demographics, PsA severity, and clinical outcomes. Patient-completed surveys captured data on PROs: 5-level EuroQol 5-dimension, Work Productivity and Activity Impairment questionnaire, Health Assessment Questionnaire-Disability Index, and 12-item Psoriatic Arthritis Impact of Disease questionnaire. Patients were compared by flare status using parametric and nonparametric tests. Multivariate regression was used to identify flare associations. Multivariate logistic regression adjusted for patient demographics and physician specialty assessed the effect of flare status.

RESULTS

Among 2238 patients (586 from the US, 1652 from Europe) managed by 572 physicians, physician-reported flare was present for 168 patients (7.5%), and self-reported flare was present for 95 patients (10% of available data). Mean (SD) flare count over 12 months was 2.2 (4.9), lasting on average 16.4 (16.2) days. Flare status was linked to worse PROs. Patients who had not flared in the last 12 months or had never flared had a higher quality of life, lower overall work impairment, and a lower degree of disability compared with patients who were currently experiencing a flare (all; P < 0.01).

CONCLUSION

Actively experiencing a flare adversely affected QOL, disability, and work productivity. PsA flares should be routinely assessed and managed in clinical care.

Prognostic factors associated with achieving minimal disease activity in early psoriatic arthritis patients treated according to “treat-to-target” st rategy within 12 months

Background. The goal of “treat-to-target” strategy (T2T) in psoriatic arthritis (PsA) is attaining remission or minimal disease activity (MDA). The benefits of T2T are shown recently in the study TICOPA and REMARCA. But prognostic factors for achievement MDA in PsA patients (pts) at the early-stage hasn’t been studied yet.Objective – to determine the prognostic factors associated with achievement of minimal disease activity within 12 months (mo) of treatment according to T2T strategy in early psoriatic arthritis patients.Methods. 77 pts (M/F=36/41) with early PsA fulfilling the CASPAR criteria were included. Mean age 36.9±10.45 years, PsA duration 11.1±10.0 mo, psoriasis duration 82.8±92.1 mo. At baseline (BL) and at 12 mo of therapy PsA activity by tender joins count (TJC) out of 68; swelling joints count (SJC) out of 66; pain; patient global assessment disease activity (PGA) using visual analogue scale; CRP; dactylitis, enthesitis by LEI and plantar fascia; BSA; HAQ and fatigue by FACIT 4 scale were evaluated. A score FACIT <30 indicates severe fatigue, the higher the score – the better the quality of life. All pts were given therapy with Methotrexate (MTX) s/c, 29 pts with ineffectiveness of MTX after 3–9 mo of treatment were added biologic DMARDs. The one-factor model of logistic regression was used to identify a group of features that are associated with achievement MDA.Results. By 12 mo of therapy, the proportion of pts who have reached MDA (5/7) were calculated. Pts were split into 2 groups: MDA+ (n=45) and MDA– (n=32).Comparative analysis of BL features in both groups and one-factor model of logistic regression showed the following features were associated with achievement MDA: TJC and SJC<3 (p<0.001); PGA≤20 mm (p<0.001); pain≤15 mm (p<0.001); CRP≤5 mg/l (p<0.03); HAQ≤0.5 (p<0.001); FACIT>30 points (p<0.021); absent of entesitis (p<0.003), dactylitis (p<0.029) and nail damage (p<0.012). Early PsA pts with combination of these features on first visit have more chance to achieve MDA in comparison to PsA pts without them (OR=9.684 [95% CI: 4.6–20.4]).Conclusion. It is a combination of features on first visit – oligoarthritis, moderate activity, absent of entesitis, dactylitis, nail psoriasis, significant impact on function and fatigue – that constitutes a clinical prognostic factors for achievement MDA after 12 mo of treatment in pts with early PsA according T2T.

Effectiveness of IL-12/23 inhibition (ustekinumab) versus tumour necrosis factor inhibition in psoriatic arthritis: observational PsABio study results

OBJECTIVES

To evaluate 6-month effectiveness of ustekinumab versus tumour necrosis factor inhibitor (TNFi), analysing predictors of low disease activity (LDA)/remission.

METHODS

PsABio is a prospective, observational cohort study of patients with psoriatic arthritis (PsA) at 92 sites in eight European countries, who received first-line to third-line ustekinumab or a TNFi. Comparative achievement at 6 months of clinical Disease Activity Index for Psoriatic Arthritis (cDAPSA) LDA/remission, and minimal disease activity (MDA)/very LDA using propensity score (PS)-adjusted multivariate logistic regression was assessed.

RESULTS

In the final analysis set of 868 participants with 6-month follow-up data (ustekinumab, n=426; TNFi, n=442), with long-standing disease and a high mean cDAPSA score (31.0 vs 29.8, respectively), proportions of patients in ustekinumab/TNFi treatment groups achieving cDAPSA LDA at 6 months were 45.7%/50.7%. cDAPSA remission was achieved in 14.9%/19.2%, and MDA in 26.4%/30.8% of patients. PS-adjusted odds ratios (OR; 95% confidence interval (CI)) of reaching cDAPSA LDA and MDA were 0.73 (0.46 to 1.15) and 0.87 (0.61 to 1.25) with ustekinumab versus TNFi, indicating no significant difference. High baseline body mass index or high cDAPSA were associated with a lower chance (OR (95% CI)) of reaching cDAPSA LDA with TNFi (0.94 (0.89 to 0.99) and 0.64 (0.52 to 0.79), respectively). Predictive factors were similar to previously published evidence, with cDAPSA and 12-item Psoriatic Arthritis Impact of Disease scores and chronic widespread pain at baseline appearing as new risk factors for unfavourable outcome. Safety data were similar between groups.

CONCLUSION

Treatment targets were reached similarly after 6 months of treatment with ustekinumab and TNFi.

Assessment of the Patient Acceptable Symptom State (PASS) in psoriatic arthritis: association with disease activity and quality of life indices

Objective

The aim of this study was to evaluate the discriminant capability of the Patient Acceptable Symptom State (PASS) according to disease activity, remission/low disease activity indices and quality of life indices in patients with psoriatic arthritis (PsA).

Methods

Consecutive patients with PsA were enrolled in this cross-sectional study. At each visit, the patients underwent a complete physical examination and their clinical/laboratory data were collected. Disease activity was assessed using the Disease Activity Score for Psoriatic Arthritis (DAPSA) and remission/low disease activity using the DAPSA minimal disease activity (MDA) and very low disease activity (VLDA) criteria. The Psoriatic Arthritis Impact of Disease (PsAID) and the Health Assessment Questionnaire-Disability Index scores were also collected. Finally, PASS was assessed by asking all patients to answer yes or no to a single question.

Results

Patients who answered yes to PASS showed a significantly better overall mean DAPSA score than those who were not in PASS. Furthermore, patients in PASS showed a significantly lower level of systemic inflammation, lower Leeds Enthesitis Index score, a significantly lower impact of disease (PsAID), lower pain and better function than patients who answered no to PASS. A moderate to good agreement was found between PASS, MDA, DAPSA low disease activity and PsAID score ≤4. Good sensitivity and specificity were found with PASS with respect to DAPSA low disease activity, and although PASS is sensitive in the identification of patients with MDA, DAPSA remission and VLDA it lacks of specificity.

Discussion

This study showed that PASS might be used as an alternative to determine disease activity in patients with PsA in real clinical practice, mainly in patients with low disease activity according to DAPSA criteria.

Gender-related differences in disease activity and clinical features in patients with peripheral psoriatic arthritis: A multi-center study

OBJECTIVE

This study sought to compare disease activity, clinical features, and patient-reported outcomes concerning anxiety, depression, fatigue, function, quality of life, and fibromyalgia between female and male patients with peripheral PsA in a Turkish population.

METHODS

This multi-center Turkish League Against Rheumatism (TLAR) Network study included 1038 patients (678 females, 360 males) diagnosed with peripheral PsA according to the CASPAR criteria. The demographic and clinic parameters of the patients were recorded. Disease activity was evaluated using the scores of DAS28 and cDAPSA. Remission, minimal disease activity (MDA), and very low disease activity (VLDA) were determined. Health Assessment Questionnaire (HAQ), Short-Form-36 (SF-36), Hospital Anxiety and Depression Scale (HAD), fatigue VAS (0-10), and Fibromyalgia Rapid ScreeningTool (FiRST) were used. Disease activity and patient-reported outcomes were compared in male and female patients, and the predictors of MDA for both genders were analyzed.

RESULTS

The patients' mean age was 47.6years (SD: 12) for females and 46.3years (SD: 12.3) for males. In terms of DAS28 and cDAPSA, female patients had significantly higher disease activity scores, while male patients had significantly higher remission rates (P<0.05). There was a significant difference in the rate of MDA in favor of males (P<0.05), but not in VLDA. The incidences of dactylitis, enthesitis, tenosynovitis, and inflammatory bowel disease were similar in male and female patients, except for spondylitis, which was higher in males (P<0.05). Overall, although there was no significant between-group difference in age and disease duration, female patients had significantly higher BMI and late-onset disease (P<0.05). Female patients had higher HAD, HAQ, and FiRST and lower SF-36 scores than males (P<0.05). In both male and female patients, the disease activity score of cDAPSA was significantly correlated with the scores of FiRST, HAD, VAS-F, and HAQ (P<0.05). In regression analysis, tender joint count, swollen joint count, PASI, pain VAS, and enthesitis were the MDA predictors in both genders.

CONCLUSION

In patients with peripheral PsA, males are more likely to develop spondylitis while other extraarticular manifestations are similar. Female patients appear to have lower rates of remission and MDA and higher levels of disease activity. Female patients experience a more severe course of PsA, with higher levels of pain and fatigue, lower quality of life, and increased functional limitations. The predictors of MDA, i.e., tender joint count, swollen joint count, PASI, pain VAS, and enthesitis are similar between the two genders.

New Insights in Physical Therapy and Rehabilitation in Psoriatic Arthritis: A Review

Psoriatic arthritis (PsA) is a complex, multiform and chronic inflammatory disease characterized by the association of psoriasis and arthritis with other musculoskeletal and extra-articular manifestations. The treatment of PsA is rapidly evolving due to the introduction of new biologic and small-molecule drugs, and the aim of treatment is to induce a condition of remission or low disease activity in all disease domains. However, unmet treatment needs still persist for those patients with impaired function, reduced quality of life or comorbidities. In this context, physical therapy and rehabilitation could provide additional benefits by reducing disease activity and improving function. Although a large number of studies have assessed the role of physical therapy and exercise in other forms of chronic inflammatory arthritis, such as axial spondyloarthritis and rheumatoid arthritis, evidence on their effect on persons with PsA is still lacking. However, some studies have reported the potential positive role of physical therapy on the different disease domains of PsA, in helping to improve disease activity, prevent or improve articular impairment, improve pain management and improve quality of life. Here, we review current evidence on physical therapy, exercise and rehabilitation in patients with PsA. In particular, we review the literature focusing on each domain, to provide evidence of efficacy and effectiveness of exercise and rehabilitation on skin, peripheral arthritis, axial involvement, dactylitis, enthesitis and comorbidities.

Impact of Comorbidities on Disease Activity, Patient Global Assessment, and Function in Psoriatic Arthritis: A Cross-Sectional Study

INTRODUCTION

The aim of this study was to evaluate the impact of comorbidities on disease activity, patient's impact of the disease, patient global assessment, and function in psoriatic arthritis (PsA).

METHODS

Consecutive PsA patients were enrolled in this cross-sectional study. During the visit, the patients underwent a complete physical examination and clinical/laboratory data were collected, including type and number of comorbidities, recorded as simple comorbidity count (SCC). Disease activity was assessed using the Disease Activity Score for Psoriatic Arthritis (DAPSA) and the Minimal Disease Activity (MDA) was also evaluated. The Psoriatic Arthritis Impact of Disease (PsAID), the Health Assessment Questionnaire-Disability Index (HAQ-DI), and the Patient Global Assessment of disease activity (PtGA) were also collected.

RESULTS

A total of 144 patients were enrolled. At least one comorbidity was registered in 104 (72.2%) patients. The SCC was associated with DAPSA (β = 1.48, p = 0.013), PsAID (β = 0.41, p < 0.01), HAQ-DI (β = 0.11, p < 0.01) and PtGA (β = 0.50, p < 0.01). The comorbidities that showed an impact on outcome measures were anxiety and fibromyalgia (FM). Anxiety showed an impact on DAPSA (β = 14.46, p < 0.001), PsAID (β = 1.98, p = 0.039) and HAQ-DI (β = 0.54, p = 0.036). FM showed an impact on DAPSA (β = 6.46, p = 0.025), PsAID (β = 2.88, p < 0.001), HAQ-DI (β = 0.70, p < 0.001), PtGA (β = 2.00, p = 0.014), and MDA (β = - 2.79, p = 0.01). The median PtGA value was different among patients with different numbers of comorbidities.

CONCLUSIONS

This study showed that comorbidities, either as a simple comorbidity count number or as single comorbidity, might have an impact on the main domains affecting PsA patients in real clinical practice.