Psoriatic arthritis assessment and treatment update

Pharmacologic Treatment Strategies in Psoriatic Arthritis

PURPOSE

The goal of this narrative review was to provide current data on psoriatic arthritis (PsA) therapeutic strategies, supporting treatment decisions with a domain-based approach.

METHODS

This narrative review of treatment strategies for PsA focused on several disease domains (ie, peripheral arthritis, enthesitis, axial disease, dactylitis, skin and nail disease), as well as the so-called "related conditions" of uveitis, Crohn's disease, and ulcerative colitis. We searched PubMed, EMBASE, international guidelines, and recent congress abstracts.

FINDINGS

Currently, multiple approved treatment options offer a wide range of options, such as tumor necrosis factor (TNF) inhibitors; inhibitors of interleukin-17 (IL-17), IL-12/23 (IL-12/23), IL-23 (IL-23), and Janus kinase; the phosphodiesterase 4 inhibitor apremilast; and the T-cell modulator abatacept. However, no treatment option shows clear superiority concerning efficacy on peripheral arthritis and dactylitis over the others, whereas limited evidence suggests that the IL-17 inhibitor ixekizumab and the IL-12/23 inhibitor ustekinumab may be superior to TNF inhibitors in treating enthesitis. Recent data on enthesitis have also shown promising results for methotrexate. Treatment of axial PsA is mostly derived from axial spondyloarthritis, and more data are needed focusing on this specific subgroup of PsA patients. Thus far, the most important finding from the only randomized controlled trial in this specific population is that the IL-17 inhibitor secukinumab was superior to placebo in terms of clinical and radiologic end-points in axial PsA. Regarding psoriatic skin involvement, head-to-head trials in PsA as well as skin psoriasis showed the superiority of IL-17, IL-23, and IL-12/23 inhibitors over TNF inhibitors. When treating PsA with concurrent uveitis, according to the existing data, monoclonal TNF inhibitor antibodies should be preferred. In PsA and concomitant inflammatory bowel disease, treatment decisions must include the consideration of which specific type of inflammatory bowel disease (Crohn's disease or ulcerative colitis) is present, as some of the agents either lack data or are ineffective in treating these 2 conditions. In both types, IL-17 inhibitors should be avoided. When determining treatment strategy, comorbidities should be carefully assessed, and the corresponding risk profile of the respective treatment modalities should be taken into consideration.

IMPLICATIONS

There are many approved therapeutic options for treating patients with PsA, and additional emerging treatment options are in the pipeline. Individualized treatment decisions for each patient, depending on the leading disease phenotype, underlying comorbidities, and patient preferences, should be made based on shared decision-making.

Psoriatic arthritis: From pathogenesis to pharmacologic management

The pathogenesis of psoriatic arthritis (PSA) is still a matter of debate. A favourable genetic background is interwoven with environmental triggering factors in a complex network. Shared antigens and the recirculation of immune cells may account for the clinical manifestations, involving both cutaneous and articular sites. A favourable genetic background has been demonstrated in many genomic and proteomic studies, being associated to polymorphic variants of the genes coding for Major Histocompatibility Complex I and cytokine pathways. In genetic-predisposed individuals, triggering factors, like infections, dysbiosis or mechanic stress may promote the development of the disease. The subsequent activation of the innate and adaptive immune system, following the stimulation of Toll-like Receptors, culminates in the expansion of dendritic cells, macrophages, CD4+ and CD8+ T cells, neutrophils, monocytes, Natural Killer lymphocytes and other cells with the final inflammation and damage of skin, joint and enthesis. Particularly, the activation of CD4+ T helper 17 lymphocytes represents a crucial point in the pathogenesis of the disease. The participation of the visceral adipose tissue may amplify the inflammatory process by means of the synthesis of pro-inflammatory adipokines. Current therapeutic algorithms address the variety of clinical manifestations with a tailored strategy aiming to achieve the best control of the symptoms with minimal side effects. Conventional immunosuppressive drugs, biologic agents and synthetic small molecules offer different attack routes and may be chosen individually or in combination according to the phenotype of the disease.

Introduction of a metabolic joint asymmetry score derived from conventional bone scintigraphy. A new tool to differentiate psoriatic from rheumatoid arthritis

AIM

Clinical differentiation of psoriatic arthritis (PsA) and rheumatoid arthritis (rA) based on the pattern of joint involvement can be difficult; the frequent form of PsA with polyarthritis of the peripheral joints may sometime resemble rA. We investigated a metabolic joint asymmetry score (MJAS), reflecting the overall asymmetric joint involvement on conventional bone scintigraphy, for differentiating PsA from rA in patients presenting with peripheral polyarthritis.

PATIENTS, METHODS

106 patients (n = 61, PsA; n = 45, rA) with peripheral polyarthritis (≥ 5 joints) as well as 26 control subjects with no history of chronic joint disorders were analyzed. The intensity of articular 99mTc-MDP uptake in 40 peripheral joint pairs was scored regarding the bilateral difference of each joint based on a scale of 0-2 (no significant, moderate, and marked asymmetry, respectively). The patient's MJAS was defined as the sum of uptake difference scores of all joint pairs. The association of MJAS with the underlying condition (Psoriasis criteria, Revised Criteria of the ACR) was examined.

RESULTS

5280 peripheral joint pairs were investigated. There was no significant difference in the total number of involved joints in PsA 15.0 ± 8.2 versus rA 17.5 ± 8.8 patients (p = 0.132), but significantly less involvement in the control group (6.7 ± 5.0, p < 0.001). MJAS was markedly higher in PsA (17.0 ± 9.6) than in rA (4.8 ± 3.9, p < 0.001), and correlated with the total number of involved joints in PsA (r = 0.516, p < 0.001), but not in rA (r = 0.078, p = 0.380). The MJAS disparity between PsA and rA persisted after exclusion of the DIP joints (14.4 ± 7.7 vs. 4.4 ± 3.3; p<0.001).

CONCLUSIONS

The new reproducible semi-quantification method for the asymmetry of metabolic joint involvement permits differentiation of psoriatic from rheumatoid peripheral arthritis with MJAS being markedly higher in patients with PsA as compared to rA patients. The score may offer an effective complementary tool for characterizing patients with peripheral polyarthritis.

Peroxisome proliferator-activated receptor agonists (PPARs): a promising prospect in the treatment of psoriasis and psoriatic arthritis

Psoriasis is a polygenic, inflammatory and progressive disease, characterized by an abnormal differentiation and hyperproliferation of keratinocytes, associated with impaired immunologic activation and systemic disorders, while psoriatic arthritis is a chronic inflammatory articular disease. Pathophysiology of psoriasis comprises a dysfunction of the immune system cells with an interactive network between cells and cytokines supporting the initiation and perpetuation of disease and leading to inflammation of skin, enthesis and joints. Recent studies have shown an important role of systemic inflammation in the development of atherosclerosis. Corroborating these findings, patients with severe Psoriasis have marked incidence of psoriatic arthritis, cardiovascular diseases, hypertension, dyslipidemia, obesity and diabetes mellitus, showing an increased risk for acute myocardial infarction, which suggests that the condition is not restricted to the skin. Nuclear receptors are ligand-dependent transcription factors, whose activation affects genes that control vital processes. Among them the peroxisome proliferator-activated receptor is responsible for establishing the relationship between lipids, metabolic diseases and innate immunity. In the skin, peroxisome proliferator-activated receptors have an important effect in keratinocyte homeostasis, suggesting a role in diseases such as psoriasis. The peroxisome proliferator-activated receptors agonists represent a relevant source of research in the treatment of skin conditions, however more clinical studies are needed to define the potential response of these drugs in patients with psoriasis and psoriatic arthritis.

Clinical response, drug survival, and predictors thereof among 548 patients with psoriatic arthritis who switched tumor necrosis factor α inhibitor therapy: results from the Danish Nationwide DANBIO Registry

OBJECTIVE

To describe the frequency of treatment switching and outcomes among patients with psoriatic arthritis (PsA) who switched tumor necrosis factor α inhibitor (TNFi) agents in routine care.

METHODS

We conducted an observational cohort study based on the Danish nationwide DANBIO registry. Treatment outcomes were evaluated using the American College of Rheumatology criteria for 20% improvement (ACR20)/ACR50/ACR70, European League Against Rheumatism (EULAR) response criteria for good response, and the 28-joint count Disease Activity Score (DAS28) (remission). Kaplan-Meier and regression analyses were used for drug survival analyses and to identify predictors of outcome after treatment switching.

RESULTS

Of 1,422 patients starting TNFi agents, 548 patients (39%) switched to a second biologic drug during up to 10 years of followup. Median followup was 2.3 years (interquartile range [IQR] 1.0-4.3 years). Switchers were more frequently women (56% versus 45%), had a shorter disease duration (3 versus 4 years), a higher median Health Assessment Questionnaire (HAQ) score (1.1 [IQR 0.6-1.6] versus 0.9 [IQR 0.5-1.4]), DAS28 (4.8 [4.0-5.7] versus 4.4 [3.6-5.2]), pain score on a visual analog scale (VAS) (65 mm [46-77] versus 62 mm [40-75]), and fatigue score on a VAS (69 mm [50-83] versus 64 mm [42-80] mm) (all P < 0.05 at start of first TNFi). During the first and second treatment, HAQ, DAS28, and VAS scores and C-reactive protein levels had decreased after 6 months (all P < 0.05), and median drug survival was 2.2 versus 1.3 years (P < 0.001). Lower fatigue score increased survival of the second TNFi. After switching, the proportions of patients achieving a sustained ACR20, ACR50, ACR70, EULAR good response, and DAS28 remission after 3-6 months were 22% (number needed to treat [NNT] 4.5), 13% (NNT 7.9), 5% (NNT 20), 19% (NNT 5.3), and 34% (NNT 2.9), respectively. Response rates were lower during the second treatment (all P < 0.01 versus first TNFi). At the 2-year visit, 47% of switchers had achieved an ACR20 response. No differences between drug-drug combinations were found.

CONCLUSION

Thirty-nine percent of the patients with PsA switched TNFi agents. Response rates and drug survival were lower after switching; however, half of the switchers had an ACR20 response 2 years after starting the first TNFi.

Psoriatic arthritis

Psoriatic arthritis (PsA) is a chronic inflammatory spondyloarthritis that occurs in combination with psoriasis. The exact prevalence of PsA is unknown, and its pathogenesis has not yet been fully elucidated. Genetic, environmental, and immunologic factors have all been implicated. The appearance of arthritis might precede, succeed or occur concomitant with skin lesions. PsA is sometimes considered a benign form of arthritis, but it affects patient quality of life and also causes functional impairment. Up to 20% of affected patients exhibit extremely destructive and disfiguring forms of the disease, and PsA is associated with increased mortality. The treatment of PsA aims to provide relief from signs and symptoms of the disease, prevent structural damage to joints, improve patient quality of life and decrease mortality. The choice of treatment depends on the severity of clinical presentation. The use of immunobiological agents is restricted to cases that do not respond to conservative treatment.

[Psoriatric arthritis - a permanent challenge for rheumatologists and patients: part 2: imaging diagnostics, classification and therapy]

In recent years a considerable number of imaging techniques have been used to demonstrate the onset and progression of arthritis-related changes in psoriatric arthritis (PsA). Moreover the identification of new immunological pathways has resulted in a substantial improvement of available therapies for PsA increasing the chance for the individual to receive effective treatment. Although an all-embracing disease activity score is still lacking, there is a variety of symptom-related tools to adequately reflect the course of disease and to evaluate the corresponding treatment success. This manuscript aims to give an overview of the latest corresponding knowledge with respect to PsA.

The effect of overweight and obesity on psoriasis patients in Chinese Han population: a hospital-based study

BACKGROUND

Accumulating evidence indicates that psoriasis is associated with increased risk of overweight and obesity. However, few studies have investigated this relationship in Chinese Han population.

OBJECTIVE

The aim of this study was to explore the relationship between overweight/obesity and psoriasis and to evaluate the overweight/obesity effect on the clinical features of psoriasis in Chinese Han population.

METHODS

A hospital-based study was conducted, which involved in 4452 patients and 1166 controls of Chinese Han through epidemiological investigation. Controls used in the study were individuals without psoriasis from health examination centre, and other skin disease patients from outpatient department.

RESULTS

Compared with the control group, a significantly greater prevalence of overweight and obesity was observed in psoriasis patients. The estimated ORs were 1.301 (95% CI, 1.105-1.531) and 1.680 (95% CI, 1.134-2.491) respectively. The disease severity of psoriasis measured by psoriasis area and severity index (PASI) was statistically correlated with body mass index (BMI) (r = 0.184, P < 0.01). Moreover, a high proportion of overweight patients had affected hands or/and feet, buttocks, trunk, legs, arms and arthritis (P < 0.01).

CONCLUSIONS

Our study suggested that psoriatic patients have a higher prevalence of overweight and obesity compared with non-psoriatic patients in Chinese Han population. Overweight and obesity has different risk effect on severity and manifestations of psoriasis and might be useful for better evaluating psoriasis clinically.

Are current available therapies disease-modifying in spondyloarthritis?

Disease modification in spondyloarthritis should target the improvement of symptoms and preservation of function. Therefore, inhibition of structural damage caused by the disease processes appears essential. In spondyloarthritis, structural damage results mainly in progressive ankylosis of the spine and peripheral joint destruction. Currently available therapies for the treatment of spondyloarthritis appear effective at inhibiting tissue destruction but, with the exception of celecoxib, do not appear to affect new tissue formation leading to ankylosis. In this article, we discuss clinical and pathophysiological concepts of disease modification in spondyloarthritis, challenges in its evaluation, recent clinical data and new concepts that may help explain structural damage as well as the onset and progression of disease.

Managing inflammatory arthritides: Role of the nurse practitioner and physician assistant

PURPOSE

To review the current management of the inflammatory arthritides, including rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis. This review examines the role of the nurse practitioner (NP) and physician assistant (PA) in the management of these chronic diseases.

DATA SOURCES

A review of the scientific literature and current guidelines regarding the management of inflammatory arthritides.

CONCLUSIONS

NPs and PAs play important roles in the interdisciplinary team involved in the treatment of patients with chronic inflammatory arthritic conditions. The management of inflammatory arthritides has evolved with the development of new treatment strategies and is focused on early intervention and minimizing progressive joint damage. NPs and PAs are ideally positioned to educate patients regarding treatment options and other important aspects of the disease process and to monitor disease activity using a number of validated instruments.

IMPLICATIONS FOR PRACTICE

Through active disease management, NPs and PAs can influence their patients to make better, more informed choices regarding treatment, which may optimize patient outcomes.

Treatment response, drug survival, and predictors thereof in 764 patients with psoriatic arthritis treated with anti-tumor necrosis factor α therapy: results from the nationwide Danish DANBIO registry

OBJECTIVE

To investigate disease activity, treatment response, and drug survival, and predictors thereof, among Danish patients with psoriatic arthritis (PsA) receiving their first treatment series with a tumor necrosis factor α (TNFα) inhibitor.

METHODS

Patients with PsA were identified from a prospective nationwide rheumatologic database, the Danish biologics registry DANBIO, using data registered from 2000-2009. Information was obtained on the patients' clinical response to anti-TNFα treatment (defined as achievement of the American College of Rheumatology 20% [ACR20], ACR50, and ACR70 improvement criteria or a European League Against Rheumatism [EULAR] good response at least once during the first 6 months of treatment) and duration and rate of drug adherence (referred to as drug survival), as well as predictors thereof.

RESULTS

Of 764 patients with PsA, 320 received adalimumab, 260 infliximab, and 184 etanercept. Median drug survival was 2.9 years, and 1-year and 2-year drug survival rates were 70% and 57%, respectively. Clinical parameters that showed improvement over 6 months were the C-reactive protein (CRP) level, Health Assessment Questionnaire score, and 28-joint Disease Activity Score. Male sex, CRP level >10 mg/liter, concomitant methotrexate use, and low patient health visual analog scale score at baseline were associated with longer drug survival. Improvement was achieved by 59%, 45%, 24%, and 54% of patients according to the ACR20, ACR50, ACR70 response criteria and EULAR good response, respectively. A CRP level >10 mg/liter was predictive of the improvement responses (odds ratio [OR] 2.6 for ACR20, OR 3.0 for ACR50, OR 3.6 for ACR70, and OR 2.2 for EULAR good response).

CONCLUSION

In these patients with PsA treated with their first TNFα inhibitor in clinical practice, high drug adherence and responder rates were observed. Moreover, increased levels of CRP at baseline were associated with both good treatment responses and continued treatment, which may be of clinical value in selecting the patients most likely to benefit from treatment with TNFα inhibitors.

A comparison of an interferon-gamma release assay and tuberculin skin test in refractory inflammatory disease patients screened for latent tuberculosis prior to the initiation of a first tumor necrosis factor α inhibitor

Treatment with TNFα inhibitors increases risk of reactivating a latent tuberculosis\infection (LTBI). Therefore screening, prior to therapy with TNFα inhibitors, has been recommended, even in low-endemic areas such as well-developed Western Europe countries. We evaluated interferon-gamma release assay (IGRA), as opposed to tuberculin skin test (TST), for detection of LTBI in refractory inflammatory disease patients prior to the initiation of a first TNFα inhibitor. In addition, we evaluated the impact of impaired cellular immunity on IGRA. Patients starting on TNFα inhibition were screened for LTBI by TST and IGRA (Quantiferon-TB Gold). Data on tuberculosis exposure and Bacillus Calmette–Guérin (BCG) vaccination were obtained. Cellular immunity was assessed by CD4⁺ T lymphocyte cell count. Nine out of 56 patients (16.1%) tested positive for LTBI. A concordant positive result was present in three patients with a medical history of tuberculosis exposure. Six patients with discordant test results had either: (1) a negative TST and positive IGRA in combination with a medical history of tuberculosis exposure (n = 1) or (2) a positive TST and negative IGRA in combination with BCG vaccination (n = 3) or a medical history of tuberculosis exposure (n = 2). CD4⁺ T lymphocyte cell counts were within normal limits, and no indeterminate results of IGRA were present. IGRA appears reliable for confirming TST and excluding a false positive TST (due to prior BCG vaccination) in this Dutch serie of patients. In addition, IGRA may detect one additional case of LTBI out of 56 patients that would otherwise be missed using solely TST. Immune suppression appears not to result significantly in lower CD4⁺ T lymphocyte cell counts and indeterminate results of IGRA, despite systemic corticosteroid treatment in half of the patients. Confirmation in larger studies, including assessment of cost-effectiveness, is required.

Etanercept treatment patterns in managed-care patients with psoriasis or psoriatic arthritis

OBJECTIVE

To evaluate the actual dosing of etanercept in US commercially insured patients with psoriatic disease, to estimate treatment cost.

METHODS

This study evaluated medical and pharmacy claims in a US commercial claims database from November 1, 2003 through June 30, 2008. Biologic-naïve patients diagnosed with psoriasis, psoriatic arthritis, or both, who filled prescriptions for etanercept and were enrolled for ≥ 6 months before the first claim and 1 year after, were included. Patients with rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, or ulcerative colitis during the study period were excluded.

RESULTS

Among 2,359 patients, diagnoses included psoriasis (n = 1,810), psoriatic arthritis (n = 212), and both diseases (n = 337). Psoriasis patients used a mean 98% (standard deviation [SD] 28%) and psoriatic arthritis patients used 107% (SD 31%) of label-recommended etanercept doses.

CONCLUSIONS

Overall, patients with psoriatic disease used 98-104% of the expected etanercept dose, depending on whether the expected dose for patients with both diagnoses was the psoriasis or psoriatic arthritis dose. This study does not evaluate effectiveness or clinicians' intent and may not be representative of other populations. Nevertheless, average usage was as expected for all cohorts, providing a basis for cost estimation.