Physician’s Global Assessment in Psoriatic Arthritis: A Multicenter GRAPPA Study

The Development and Validation of a Novel Training Infographic for the Physician Global Visual Analog Scale in Psoriatic Arthritis

OBJECTIVE

Psoriatic arthritis (PsA) is a heterogenous condition with musculoskeletal and skin manifestations. The physician global visual analog scale (VAS) is an important component of many composite scores used in clinical trials and observational studies. Currently, no training material exists to standardize this assessment.

METHODS

The Psoriatic Arthritis Validation of Physician Global VAS (PAVLOVAS) project describes the development of a novel training infographic with stakeholder involvement, which was then evaluated in a Latin square design in which 20 patients with PsA were assessed by 10 clinicians. For each group of 10 patients, 5 assessors conducted traditional assessment (consisting of 66/68-joint count, body surface area, Leeds Enthesitis Index, and dactylitis and nail counts) and 5 assessors conducted a standardized, thorough general examination informed by the infographic. Assessors switched assessment type between groups. The 3-item (3VAS) and 4VAS informed by traditional and infographic methods were compared, alongside other composite scores.

RESULTS

There was strong agreement between traditional and infographic physician global VAS (intraclass correlation coefficient [ICC] 0.69, P = 0.01). This improved to very strong agreement when incorporated into the 3VAS (ICC 0.99, P < 0.001) and 4VAS (ICC 0.99, P < 0.001). The duration of assessment was significantly less for the infographic vs traditional groups (6.5 vs 7.8 mins, P < 0.001). There was moderately high agreement between the 3VAS and 4VAS categories of disease activity, with the same categories defined by Psoriatic Arthritis Disease Activity Score (PASDAS) and Disease Activity Index for Psoriatic Arthritis (DAPSA; χ2 17.0, P = 0.049).

CONCLUSION

Our group developed and validated a novel training infographic that informs a briefer assessment of the physician global VAS than traditional assessments. This tool has potential applications in training and routine clinical practice.

Physical component of SF-36 is associated with measures of disease activity in patients with psoriatic arthritis: a real-life study from a tertiary referral centre

Psoriatic arthritis (PsA) can lead to chronic disability. The aim of this study was to explore the association between disease activity and quality of life (QoL) in patients with PsA from the usual clinical practice. The study involved 143 consecutive adult patients with PsA (49.6% women and 50.4% males), with mean age of 57.75 ± 10.91 years, and duration of disease 11.6 ± 9 years. Tender (TJC) and swollen joints count (SJC), Disease activity score (DAS) 28, patient's global assessment (PtGA), physician's global assessment (PhGA), enthesitis score, number of fingers with dactylitis, sedimentation rate (ESR) and C-reactive protein (CRP) were evaluated. The functional assessment of chronic illness therapy - fatigue scale (FACIT-F) questionnaire was used in fatigue assessment and physical health domains of Short Form (SF)-36 questionnaire were chosen to assess subjective QoL: physical functioning (PF), role limitations due to physical health (RP), bodily pain (BP) and general health (GH). Significant correlations (p < 0.001) were found between FACIT-F and all SF-36 domains. DAS28, PtGA and PhGA were significantly correlated to two or three SF-36 domains, while ESR and CRP were not significantly correlated to any of SF-36 domains. Regression analysis showed, when controlling for age, that FACIT-F, dactylitis and DAS28 were the most significant predictors of SF-36 physical health domains. Regression and factor analyses confirmed that FACIT-F was most consistently associated with SF-36 physical health domains. In our real-life study most of the analyzed clinical measures of PsA were significantly associated with physical health domains of SF-36 questionnaire. Considering the strength of those associations, we conclude that PsA activity has mild to moderate impact on health-related Qol.

Disabling foot pain and its impact on daily living among people with psoriatic arthritis in Singapore: a cross-sectional observational investigation

BACKGROUND

Psoriatic Arthritis (PsA)-related foot involvement has been shown to have a profound impact on daily functioning, with most studies having focused on predominantly Caucasian populations. The aim was to describe disabling foot pain (DFP) and its impact on daily living in PsA in Singapore.

METHODS

A cross-sectional, retrospective study was conducted using clinical data collected during a single-visit to a rheumatology clinic in Singapore. Records for adults with physician-diagnosed PsA were reviewed for sociodemographic information, disease characteristics, global disease activity and burden. Foot-specific measures included clinical assessment and the Manchester Foot Pain and Disability Index used to define DFP and evaluate between-group differences.

RESULTS

Forty-two participants with PsA (83% female, 57% Chinese, 31% Malay, 9.5% Indian, mean (SD) age 54-years (16)) attended the rheumatology clinic over the study-period. The median (IQR) disease duration was 2-years (11) and all were taking current DMARDs. Global disease measures demonstrated mild-to-moderate global disease activity and mild functional impairment, and were significantly higher in those with DFP. Despite 90% reporting to be coping well with their condition, self-care and having emotional support (n = 38), this study sample demonstrated high levels of anxiety/depression (29%), sleep disturbance (34%) and fatigue (24%), and a lack of disease- and drug-specific knowledge (64%). Further management was indicated for medication adherence counselling (48%), occupational therapy (43%), physiotherapy (36%) and podiatry (30%). Nearly half had current foot pain with 40% reporting DFP (n = 17), which caused significantly greater difficulty walking 3 km than those without DFP (p < 0.05). Rearfoot enthesitis (plantar fasciitis, Achilles enthesitis) was the most common cause of DFP (67%) with pain lasting longer than 1-year. 72% were overweight or obese, with a high proportion not engaging in any cardiovascular exercise (70%). Three of 42 participants had previously seen a podiatrist.

CONCLUSIONS

People with DFP in PsA experience more severe global disease activity, reduced mobility and higher levels of negative impact on their daily lives in Singapore. In the absence of working in a multidisciplinary-team, there is value in comprehensive assessments that have potential to capture a holistic view of personal impact and improve person-centred care in PsA.

Filling the "GAP" in Real-World Assessment of Psoriatic Arthritis Disease Activity: Performance Characteristics of a Global/Pain Composite Endpoint

INTRODUCTION

Some retrospective data sources, such as electronic health records in the USA, report composite outcome measures not fully validated in psoriatic arthritis (PsA). However, they often contain global assessments, such as a Physician Global Assessment (PhGA) and Patient Global Assessment (PatGA), along with patient-reported pain scores, which individually are considered validated in PsA. This research described the performance characteristics of a 3-item global assessment and pain (GAP) composite endpoint using data from the ixekizumab phase 3 PsA clinical trial program.

METHODS

Discrimination of GAP was assessed by comparing placebo to active treatment arms. The magnitude of treatment effect and responsiveness were compared to Disease Activity Index for PsA (DAPSA), clinical DAPSA, DAPSA28, and Psoriatic Arthritis Disease Activity Score (PASDAS) using effect size (ES) and standardized response mean (SRM), respectively. Construct validity was evaluated through correlation among the composite endpoints, and with other physician- and patient-reported outcomes. Change in GAP was compared in patients who reached low disease activity (LDA) levels based on DAPSA, cDAPSA, and PASDAS vs those who did not.

RESULTS

GAP discriminated between active treatment and placebo with statistically significant separation as early as week 1. The largest ES/SRM was seen with GAP (2.29/1.74) and PASDAS (2.47/1.68). GAP had the strongest correlation with PASDAS (0.81-0.92) and showed moderate correlations with patient-assessed physical function, low correlations with physician-assessed skin and nail psoriasis, and low to moderate correlation with physician-assessed enthesitis. A significantly greater improvement in GAP was seen in the groups achieving LDA states compared to those not (p < 0.001).

CONCLUSION

The GAP composite, an abbreviated endpoint comprising measures common in electronic health records, has promising performance characteristics and could be used to address important clinical questions regarding outcomes and impact of PsA in existing datasets. CLINTRIALS.

GOV IDENTIFIER

NCT01695239; NCT02349295.

Composite Outcome Measures for Psoriatic Arthritis: OMERACT and 3 and 4 Visual Analog Scale Progress in 2023

The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA)-Outcome Measures in Rheumatology (OMERACT) psoriatic arthritis (PsA) working group provided updates at the GRAPPA 2023 annual meeting on its work to evaluate composite outcome measures for PsA. An ongoing systematic literature review is in progress to evaluate psychometric measurement properties using the OMERACT filter 2.2 for a list of candidate composite outcome measures, which include minimal disease activity (MDA), Disease Activity for Psoriatic Arthritis (DAPSA), American College of Rheumatology (ACR) response criteria, Psoriatic Arthritis Disease Activity Score (PASDAS), Composite Psoriatic Disease Activity Index (CPDAI), 3 visual analog scale (3VAS), and 4VAS. The performance of the 3VAS and 4VAS in clinical practice and a synthesis of new data were presented, including estimates for minimal clinically important differences and thresholds of meaning, discrimination and construct validity, and longitudinal construct validity. Numeric rating scale (NRS) versions of the VAS have also been tested. Performance characteristics and psychometric properties are similar to the ASSESS study, a UK multicenter study, indicating that the VAS scales may be feasible tools for routine clinical care with a preference for the 4VAS because of superior face validity and clinical utility.

Six-Month Persistence and Multi-domain Effectiveness of Guselkumab in Adults with Psoriatic Arthritis: Real-World Data from the CorEvitas Psoriatic Arthritis/Spondyloarthritis Registry

INTRODUCTION

The aim of this work is to evaluate treatment persistence and clinical outcomes after 6 months of on-label guselkumab use in patients with rheumatologist-diagnosed active psoriatic arthritis (PsA) enrolled in the CorEvitas PsA/Spondyloarthritis Registry.

METHODS

Participants with PsA who initiated and persisted with on-label guselkumab use post-Food and Drug Administration (FDA) approval for active PsA (7/13/2020; subcutaneous 100 mg at weeks 0, 4, and every 8 weeks) at their 6-month follow-up visit (occurring through 3/31/2023) comprised the primary analysis population (On-Label Persisters). Hierarchical, multiplicity-controlled primary and secondary outcomes were mean (95% confidence interval) changes from baseline at 6 months in clinical Disease Activity Index for PsA (cDAPSA; primary), Physician Global Assessment (PGA) of arthritis and psoriasis (visual analog scale [VAS] 0-100), patient-reported pain (VAS 0-100), and percent body surface area with psoriasis (%BSA). Paired t tests determined changes that were statistically significantly different from 0 (α = 0.05).

RESULTS

Among 114 patients who initiated on-label guselkumab and had eligible baseline and 6-month visits, 90 (78.9%) had persistent use. Among these On-Label Persisters at baseline, mean duration of PsA symptoms = 13.6 years; mean cDAPSA, PGA, and patient-reported pain = 22.0, 42.3, and 57.0, respectively; 94.4% had a history of psoriasis (mean BSA 7.6%); and 18.9% and 73.3%, respectively, previously received 1 or ≥ 2 biologic/targeted synthetic disease-modifying antirheumatic drugs. The mean change (improvement) in cDAPSA was - 5.4 (- 8.5, - 2.3; p < 0.001) at 6 months. Significant mean improvements in PGA (- 19.0 [- 24.2, - 13.8]), patient-reported pain (- 9.1 [- 14.4, - 3.8]), and %BSA (- 5.1 [- 7.6, - 2.7]) were also observed (all p < 0.001).

CONCLUSIONS

In this real-world PsA population, generally characterized by longstanding, treatment-resistant, active disease at baseline, persistent guselkumab use in nearly 80% of patients with on-label use was accompanied by significant improvements in joint and skin symptoms and patient-reported pain at 6 months. These registry data support results from randomized clinical trials demonstrating the efficacy of guselkumab in improving PsA signs and symptoms.

TRIAL REGISTRATION

clinicaltrials.gov: NCT02530268.

Changes in musculoskeletal disease activity and patient-reported outcomes in patients with psoriatic arthritis treated with ixekizumab: results from a real-world US cohort

Introduction

Ixekizumab has demonstrated efficacy in pivotal trials in patients with psoriatic arthritis (PsA), both those naïve to prior biologic therapy and those with prior inadequate response or intolerance to biologics; however, minimal information is currently available on the effectiveness of ixekizumab in routine clinical practice. The objective of this study was to investigate the clinical effectiveness of ixekizumab for the treatment of PsA over 6- and 12-month follow-up periods in a real-world setting.

Methods

This retrospective cohort study included patients who initiated treatment with ixekizumab from the OM1 PremiOMTM PsA dataset, a dataset of over 50,000 patients with claims and electronic medical record (EMR) data. Changes in musculoskeletal outcomes, such as tender and swollen joint count and patient-reported pain, as well as physician and patient global assessment, as measured using the Clinical Disease Activity Index (CDAI), and Routine Assessment of Patient Index Data 3 (RAPID3) were summarized at 6 and 12 months. The RAPID3, CDAI score, and their individual components were assessed in multivariable regressions adjusting for age, sex, and baseline value. The results were stratified by biologic disease-modifying antirheumatic drug (bDMARD) status (naïve vs. experienced) and monotherapy status (monotherapy vs. combination therapy with conventional synthetic DMARDs). Changes in a 3-item composite score derived from a physician global assessment, patient global assessment, and patient-reported pain score were summarized.

Results

Among the 1,812 patients identified receiving ixekizumab, 84% had prior bDMARD treatment and 82% were monotherapy users. All outcomes improved at 6 and 12 months. For RAPID3, the mean (SD) change at 6 and 12 months was -1.2 (5.5) and -1.2 (5.9), respectively. Patients overall, bDMARD experienced, and monotherapy patients achieved statistically significant mean change in CDAI and all components from baseline to 6 and 12 months in adjusted analyses. Patients experienced an improvement in the 3-item composite score at both time points.

Conclusion

Treatment with ixekizumab was associated with improvements in musculoskeletal disease activity and PROs as assessed by several outcome measures. Future research should assess ixekizumab's clinical effectiveness in the real world across all PsA domains using PsA-specific endpoints.

Clinical Characteristics of Registry Participants with Psoriatic Arthritis Initiating Guselkumab: An Analysis from the CorEvitas Psoriatic Arthritis/Spondyloarthritis Registry

BACKGROUND

The monoclonal antibody guselkumab is the first selective inhibitor of the interleukin-23 p19 subunit approved to treat adults with moderate-to-severe plaque psoriasis and active psoriatic arthritis (PsA). Given its recent approval for active PsA, data describing patients with PsA initiating guselkumab outside of clinical trials are limited.

OBJECTIVE

This analysis describes characteristics of patients with rheumatologist-diagnosed PsA initiating guselkumab in the US-based, prospective, observational CorEvitas Psoriatic Arthritis/Spondyloarthritis Registry.

METHODS

Demographics, lifestyle/disease characteristics, comorbidities, prior treatment, and disease activity were summarized for patients with PsA initiating guselkumab from registry inception through 30 September, 2021.

RESULTS

Of 113 patients initiating guselkumab, the majority were female (63%), obese (67%), had psoriasis (89%), and initiated guselkumab as monotherapy (81%). Common comorbidities were hypertension (32%), depression (30%), and diabetes mellitus (26%). Mean tender (6.8) and swollen (2.0) joint counts, clinical Disease Activity Index for PsA score (19.1), and 57% of participants with ≥ 3% body surface area affected by psoriasis indicated moderate disease activity. Axial involvement was identified in 49% of patients. Median patient-reported pain and fatigue visual analog scale scores (0-100) were 60 and 59, respectively. Prior to guselkumab, 76% of patients had received two or more biologic disease-modifying antirheumatic drugs; the last therapy prior to guselkumab was a biologic disease-modifying antirheumatic drug in 81% of patients.

CONCLUSIONS

Registry participants with PsA initiating guselkumab had active peripheral joint and skin disease, with substantial pain and fatigue; a considerable proportion had axial involvement. Future studies will evaluate the effectiveness of guselkumab in this population.

Development of an Instrument for Patient Self-assessment in Psoriatic Arthritis

OBJECTIVE

Due to the recent pandemic caused by the coronavirus disease 2019 (COVID-19), in-person scheduled rheumatology appointments in many countries have been reserved for urgent cases only. Here we report the development of a multidimensional, patient-completed disease assessment tool for use in psoriatic arthritis (PsA).

METHODS

A focus group development and education method was used, followed by a paired observation design to assess feasibility and validity. The Psoriatic Arthritis Disease Activity Score (PASDAS) was used as the basis for the clinical assessments, but elements of this tool were modified during the focus group sessions.

RESULTS

A preliminary tool assessed tender and swollen joint counts, enthesitis, dactylitis, area of skin involved by psoriasis, and scores for global disease activity, fatigue, and spinal pain. In parallel assessments, good agreement was found between subject and healthcare professional (HCP) assessors, although overall disease activity was low.

CONCLUSION

A self-assessment tool for disease activity in PsA has been developed in conjunction with patients, demonstrating generally good agreement between patients and HCPs; however, further validation is needed before it can be recommended for clinical practice.

Physician Global Assessment as a Disease Activity Measure for Relapsing Polychondritis

OBJECTIVE

Relapsing polychondritis (RP) is a systemic inflammatory disorder of cartilage that lacks validated disease activity measures. Physician global assessment (PhGA), a measure of disease activity commonly used in rheumatologic diseases, has not been tested in a cohort of patients with RP.

METHODS

Adult patients in an observational cohort of RP underwent standardized, comprehensive evaluation at approximately 6-month intervals. PhGA was scored by three physicians from the evaluating institution on a scale of 0 to 10 for each visit. A random subset of twenty visits was scored by three, independent physicians not affiliated with the evaluating institution. Treatment change between consecutive visits was categorized as increased, decreased or unchanged.

RESULTS

78 patients were evaluated over 164 visits. The interclass correlation coefficient (ICC) (2, 1) for the three raters from the evaluating institution was excellent (0.79, 95% CI: 0.73-0.84) but was poor in the subset of cases scored by the additional raters (ICC (2,1) = 0.27, 95% CI: -0.01-0.53). Median PhGA was 3 (range 0-7). PhGA weakly correlated with CRP (r_s = 0.30, p< 0.01). In response to increased treatment, median PhGA decreased from 3 (IQR: 2-4) to 2 (IQR: 2-3) (p< 0.01) but rarely went to 0.

CONCLUSION

Within a single-center, PhGA can be used to quantify disease activity and monitor disease response in RP. Persistent disease activity despite treatment, rather than a relapsing-remitting pattern, is observed for most patients with RP. Reliability of PhGA may not generalize across different institutions. A validated disease-specific activity index is needed in RP.

Discordance between patient and physician global assessment of disease activity in Behçet's syndrome: a multicenter study cohort

BACKGROUND

To compare the patients' and physician's global assessment of disease activity in Behçet's syndrome (BS) and investigate the frequency, magnitude, and determinants of potential discordance.

METHODS

A total of 226 adult BS patients with a median (IQR) age of 46.9 (35.6-55.2) years were enrolled across Italy, Greece, Portugal, and Spain. Demographic, clinical, and therapeutic variables, as well as the patient reported outcomes, were collected at the recruitment visit. The physical (PCS) and mental (MCS) component summary scores of the Short Form Questionnaire 36 (SF-36) and the Behçet's syndrome Overall Damage Index (BODI) were calculated. Disease activity was assessed by the patients' (PtGA) and physician's global assessment (PGA) in a 10-cm visual analog scale, as well as the Behçet Disease Current Activity Form (BDCAF). Discordance (∆) was calculated by subtracting the PGA from the PtGA and defined as positive (PtGA>PGA) and negative (PtGA

RESULTS

Median PtGA and PGA scores were 2.0 (0.3-5.0) and 1.0 (0.0-3.0) cm, respectively. The discordance prevalence varied (from 29.6 to 55.3%) according to the cutoff applied, and the majority (> 80%) of disagreements were due to patients rating higher their disease activity. Higher values of BDCAF were associated to increased rate of positive discordance. When BDCAF = 0, the median (IQR) values of PtGA and PGA were 0.2 (0-2) and 0 (0-1), respectively. PCS (adjusted odds ratio (adjOR) 0.96 per unit, 95% CI 0.93-0.98, p = 0.006) and MCS (adjOR 0.96 per unit, 95% CI 0.93-0.99, p = 0.003) were independently associated with positive discordance using both cutoffs. Active ocular involvement emerged as a potential determinant of negative discordance (adjOR 5.88, 95% CI 1.48-23.30, p = 0.012).

CONCLUSIONS

PtGA and PGA should be considered as complementary measures in BS, as patients and physicians may be influenced by different factors when assessing active disease manifestations. Particularly, PtGA may be a useful tool in the assessment of BS disease activity, as it carries a low risk to misclassify an inactive disease, and may allow to capture aspects of the patient's health that negatively affect his well-being and the treatment.

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Key Words

• Behçet’s syndrome
• Disease activity
• Outcome measure
• Patients reported outcomes

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MESH Headings

• Adult
• Behcet Syndrome/diagnosis
• Behcet Syndrome/epidemiology
• Greece
• Humans
• Italy/epidemiology
• Middle Aged
• Physicians
• Severity of Illness Index
• Spain

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Grants

• Associazione Italiana Sindrome e Malattia di Behçet (SIMBA) - Onlus

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Affiliation(s)

Alberto Floris Rheumatology Unit, AOU University Clinic, Cagliari, Italy Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, SS 554, 09042, Monserrato, Cagliari, Italy
Gerard Espinosa Department of Autoimmune Diseases, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain
Luisa Serpa Pinto Hospital Santo Antonio Centro Hospitalar do Porto, Unidade de Imunologia Clinica, Porto, Portugal
Nikolaos Kougkas Rheumatology, Clinical Immunology and Allergy Unit, University of Crete, Heraklion, Greece
Andrea Lo Monaco Rheumatology Unit, AOU S. Anna di Ferrara, University of Ferrara, Ferrara, Italy
Giuseppe Lopalco Rheumatology Unit, University of Bari, Bari, Italy
Ida Orlando Rheumatology Unit, University of Siena, Siena, Italy
George Bertsias Rheumatology, Clinical Immunology and Allergy Unit, University of Crete, Heraklion, Greece
Luca Cantarini Rheumatology Unit, University of Siena, Siena, Italy
Ricard Cervera Department of Autoimmune Diseases, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Catalonia, Spain
João Correia Hospital Santo Antonio Centro Hospitalar do Porto, Unidade de Imunologia Clinica, Porto, Portugal
Marcello Govoni Rheumatology Unit, AOU S. Anna di Ferrara, University of Ferrara, Ferrara, Italy
Florenzo Iannone Rheumatology Unit, University of Bari, Bari, Italy
Alessandro Mathieu Rheumatology Unit, AOU University Clinic, Cagliari, Italy Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, SS 554, 09042, Monserrato, Cagliari, Italy
Piergiorgio Neri Ophthalmology Clinic, Università Politecnica delle Marche, Ancona, Italy Cleveland Clinic Abu Dhabi, Eye Institute, Abu Dhabi, United Arab Emirates
Ana Martins Silva Neurology Department, Centro Hospitalar do Porto/Hospital de Santo António, Porto, Portugal
Carlos Vasconcelos UMIB Abel Salazar Biomedical Sciences Institute, University of Porto, Porto, Portugal
Monica Muntoni Associazione Italiana Sindrome e Malattia di Behçet (SIMBA), Pontedera, Italy
Alberto Cauli Rheumatology Unit, AOU University Clinic, Cagliari, Italy Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, SS 554, 09042, Monserrato, Cagliari, Italy
Matteo Piga Dipartimento di Scienze Mediche e Sanità Pubblica, Università di Cagliari, SS 554, 09042, Monserrato, Cagliari, Italy.

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