Time to address the challenge of difficult to treat psoriatic arthritis: results from an international survey

Deciphering difficult-to-treat psoriatic arthritis (D2T-PsA): a GRAPPA perspective from an international survey of healthcare professionals

Objectives

This study contributes to the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)'s effort to define 'difficult-to-treat' PsA (D2T-PsA), leveraging insights of healthcare professionals who are GRAPPA members. The primary objective is to inform GRAPPA's D2T PsA project, ensuring the consensus definition reflects clinical experience and expertise.

Methods

An online survey was conducted among GRAPPA's healthcare professionals managing PsA patients. The survey covered demographic details, structured questions, and open-ended queries to gather comprehensive insights into the experts' viewpoints.

Results

About 223 physicians completed the survey, comprising 179 (80.2%) rheumatologists and 40 (17.9%) dermatologists. The majority, 184 (82.5%), favoured establishing distinct definitions for D2T-PsA and complex-to-manage PsA (C2M-PsA). Furthermore, 202 (90.5%) supported a definition that includes objective inflammation signs (clinical, laboratory, imaging, among others). However, opinions varied on the criteria for prior treatment failures, with most (93, 41.7%) favouring a definition that includes at least one conventional synthetic disease-modifying anti-rheumatic drug and two or more biological- or targeted-synthetic-DMARDs with different mechanisms of action.

Conclusion

The survey reveals a majority opinion among GRAPPA experts favouring the differentiation between D2T-PsA and C2M-PsA, and the inclusion of objective inflammatory markers in these definitions. However, there is less than 50% agreement on the specific treatment failure criteria, particularly regarding the number of therapies needed to classify PsA as D2T. These findings suggest a need for continued discussion to reach a more unified approach in defining D2T-PsA, reflecting the complexity of the condition.

Unmet needs in psoriatic arthritis, a narrative review

Psoriatic arthritis is a chronic rheumatic disease that poses challenges in its diagnosis, evaluation, and management. The heterogeneity in the manifestations and the absence of definitive diagnosis biomarkers often complicates the process of accurate diagnosis. Furthermore, the involvement of multiple disease domains poses difficulties in assessing disease activity and defining the concept of remission. Despite therapeutic advancements, a subset of patients remains refractory to treatment, leading to the emergence of the concept of "difficult-to-treat" patients and the necessity for novel therapeutic approaches (e.g., drugs with novel mechanisms of action; combinations of treatments). This review addresses key unmet needs in psoriatic arthritis, in terms of diagnosis, classification, evaluation, comorbidities and treatment.