Gender-specific differences in patients with psoriatic arthritis receiving ustekinumab or tumour necrosis factor inhibitor: real-world data

[Clinical and instrumental characteristics of psoriatic arthritis in men and women. Data from a cohort observational study]

AIM

To study and compare the clinical and imaging characteristics of psoriatic arthritis (PsA) in men and women.

MATERIALS AND METHODS

The study included 956 PsA patients observed in the Russian register, 411 (43%) men and 545 (57%) women. The average age of men/women was 46.0±16.50/50.7±17.20 years (p<0.001), the duration of PsA was 9.9±6.4/10.3±7.6 years (p>0.05), the age at the time of PsA establishment was 37.1±12.30/41.8±13.5 years (p<0.001). Rheumatological examination, X-ray of the pelvis, hands, feet were performed, the LEI, plantar fascia tenderness, body surface area (BSA), body mass index (BMI), CRP,HLA-B27 were determined. Patients filled out assessment scales of pain (Pain), disease activity (patient global assessment of disease activity - PGA), questionnaires HAQ-DI. The indices of Disease Activity in PSoriatic Arthritis (DAPSA), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), criteria of minimal disease activity (MDA) were evaluated.

RESULTS

The following differences in the course of PsA in men/women were revealed: X-ray sacroiliitis was detected in 175 (42.6%)/153 (28.1%); p<0.001; the presence of erosions of the joints of the hands and feet - 138 (33.6%)/170 (31.2%); p=0.435; LEI≥3 - 34 (11.4%)/78 (20.9%); p=0.001; Pain - at 48.5±22.60/51.5±22.80 mm VAS; p=0.043; PGA - 50.2±23.07/54.0±21.91 mm VAS; p=0.010; moderate and severe functional disorders (HAQ-DI) were more often observed in women (p=0.002 and p<0.001, respectively); the average value of DAPSA is 26.4±16.8/31.9±22.58; p<0.001; average BASDAI value: 2.7±2.83/1.8±2.78; p<0.001; MDA was achieved in 13 (3.2%)/22 (4.1%); p=0.486; BSA>10% - 54 (13.1%)/102 (18.7%); p=0.021; comorbid diseases - 154 (37%)/277 (51%); p<0.001. At the time of inclusion in the register, the proportion of patients receiving biologic disease-modifying anti-rheumatic drugs was higher in the group of men.

CONCLUSION

Our data, based on a large cohort study, demonstrate that PsA debuts in women at a later age than in men, the course of the disease is characterized by higher activity of peripheral arthritis, more pronounced functional disorders and a high prevalence of comorbid diseases. This creates a heavier burden of PsA in women and indicates that gender is an important characteristic of the patient that should be used to predict the course, therapeutic response and progression of the disease.

Sex Differences in the Effectiveness of First-Line Tumor Necrosis Factor Inhibitors in Psoriatic Arthritis: Results From the European Spondyloarthritis Research Collaboration Network

OBJECTIVE

Women with psoriatic arthritis (PsA) may have reduced tumor necrosis factor inhibitor (TNFi) effectiveness compared to men. We examined sex differences in treatment response and retention rates during 24 months of follow-up among patients with PsA initiating their first TNFi.

METHODS

Data from patients with PsA across 13 European Spondyloarthritis Research Collaboration Network registries starting their first TNFi were pooled. Logistic regression was used to analyze the association between sex and treatment response using low disease activity (LDA) according to the Disease Activity Score in 28 joints using the C-reactive protein level (DAS28-CRP) (<3.2) at six months as the primary outcome. Analyses were adjusted for age, country, conventional synthetic disease-modifying antirheumatic drug treatment, and TNFi start year. Retention rates were explored using the Kaplan-Meier estimator.

RESULTS

We analyzed the treatment response of 7,679 patients with PsA (50% women) with available data on LDA at six months. At baseline, women and men had similar characteristics, including mean DAS28-CRP (women vs men, 4.4 [SD 1.2] vs 4.2 [SD 1.2]), though patient-reported outcome measures were worse in women. At six months, 64% of women and 78% of men had LDA (relative risk [RR] 0.82; 95% confidence interval [CI] 0.80-0.84). This difference was similar after adjustment (RR 0.83; 95% CI 0.81-0.85). TNFi retention rates were evaluated in 17,842 patients with PsA. Women had significantly lower retention rates than men at all time points (women 79%, 64%, and 50% vs men 88%, 77%, and 64% at 6, 12, and 24 months, respectively).

CONCLUSION

Despite comparable disease characteristics at baseline, women with PsA have reduced treatment response and retention rates to their first TNFi, highlighting the need to consider sex differences in PsA research and management.

Differences in treatment response between female and male psoriatic arthritis patients during IL-12/23 therapy with or without methotrexate: post hoc analysis of results from the randomised MUST trial

BACKGROUND

The influence of sex on treatment outcomes during interleukin-12/23 therapy in patients with psoriatic arthritis (PsA) has not been explored.

OBJECTIVE

To conduct exploratory post hoc analyses of sex-stratified data from the MUST trial, an investigator-initiated, multicentre, phase 3b study in which patients with active PsA initiating treatment with open-label ustekinumab were randomised to treatment with placebo or methotrexate (MTX).

METHODS

We evaluated baseline characteristics, key treatment outcomes and adverse events stratified by sex, with a focus on outcomes that did not include erythrocyte sedimentation rate (ESR) as a component due to the known elevation of ESR in females.

RESULTS

A total of 166 patients were treated with ustekinumab+MTX (37 female, 50 male) or ustekinumab+placebo (32 female, 47 male). At baseline, females had a significantly longer time since PsA diagnosis and greater impairment in physical function, but similar joint counts. At week 24, both females and males showed marked improvements to ustekinumab with or without MTX. Females generally had numerically reduced treatment responses compared with males, although differences did not achieve statistical significance. MTX did not show an overall effect on treatment outcomes, but was associated with faster enthesitis responses in males only. Adverse events were generally comparable, but females in the ustekinumab+MTX group had higher levels of gastrointestinal disorders.

CONCLUSION

Females and males with PsA had differences in baseline characteristics, treatment responses and adverse events during therapy. A better understanding of sex-based differences in PsA may help optimise treatment.

Influence of sex on the persistence of different classes of targeted therapies for psoriatic arthritis: a cohort study of 14 778 patients from the French health insurance database (SNDS)

BACKGROUND

Sex differences in phenotype presentation, disease trajectory and treatment response in psoriatic arthritis (PsA) have been reported. Nevertheless, whether classes of targeted therapies differentially affect men and women with PsA remains unclear.

OBJECTIVES

To assess the effect of sex on the long-term persistence of each class of targeted therapies in PsA.

METHODS

This nationwide cohort study involved the administrative healthcare database of the French health insurance scheme linked to the hospital discharge database. We included all adults with PsA who were new users of targeted therapies (not in the year before the index date) during 2015-2021 and studied all treatment lines during the study period. Persistence was defined as the time from treatment initiation to discontinuation and was estimated by the Kaplan-Meier method. Comparison of persistence by sex involved multivariate frailty models with conventional synthetic disease-modifying antirheumatic drugs and prednisone as time-dependant variables.

RESULTS

We included 14 778 patients with PsA who were new users of targeted therapies: 8475 (57%) women (mean age 50±13 years; 15 831 lines), 6303 (43%) men (mean age 51±13 years; 10 488 lines). Overall, 1-year persistence was 52% for women and 62% for men and at 3 years it was 27% and 39%, respectively. After adjustments, persistence was lower for women than men for inhibitors of tumour necrosis factor (TNFi) (adjusted HR (HRa) 1.4, 99% CI 1.3 to 1.5) and interleukin 17 inhibitor (IL17i) (HRa 1.2, 99% CI 1.1 to 1.3) but not IL12/23i (HRa 1.1, 99% CI 0.9 to 1.3), IL23i (HRa 1.1, 99% CI 0.7 to 1.5) or Janus kinase inhibitor (JAKi) (HRa 1.2, 99% CI 0.9 to 1.6).

CONCLUSION

The treatment persistence was lower for women than men for TNFi and IL17i but not for IL12/23i, IL23i or JAKi.

Managing psoriatic arthritis in different clinical scenarios

INTRODUCTION

Psoriatic arthritis (PsA) is a chronic, immune-mediated disease characterized by synovio-entheseal inflammation. It is estimated to affect around 30% of patients with psoriasis and significantly reduces patients' physical function and quality of life. There is a growing number of treatment options for PsA, but due to the heterogeneous clinical features of the disease and prevalence of comorbidities, managing PsA can be challenging.

AREAS COVERED

In this article, we review current understanding of the disease and available pharmacological options. Based on published treatment guidelines, emerging evidence and clinical experience, we provide our expert opinion on treatment strategies, taking into consideration the predominant disease domain and the presence of comorbidities, which can impact treatment decisions and clinical outcomes.

EXPERT OPINION

Biological and targeted synthetic disease-modifying agents are dramatically improving the lives of patients with PsA. Biosimilar TNF inhibitors offer a particularly versatile and cost-effective option, whilst newer biologics and targeted synthetic molecules that can be used to treat most domains of psoriatic disease are an attractive alternative to TNF inhibitors. Despite a lack of consensus on treatment sequencing and tapering, it is important that PsA patients, especially those with comorbidities, are looked after by a multidisciplinary team to optimize their care.