Continuous improvement through differential trajectories of individual minimal disease activity criteria with guselkumab in active psoriatic arthritis: post hoc analysis of a phase 3, randomized, double-blind, placebo-controlled study

BACKGROUND

To explore the trajectory of, and factors contributing to, achievement of individual criteria of minimal disease activity (MDA) in patients with active psoriatic arthritis (PsA) treated with guselkumab.

METHODS

The Phase 3, randomized, placebo-controlled DISCOVER-2 study enrolled adults (N = 739) with active PsA despite standard therapies who were biologic/Janus kinase inhibitor-naive. Patients were randomized 1:1:1 to guselkumab 100 mg every 4 weeks; guselkumab 100 mg at week 0, week 4, then every 8 weeks; or placebo. In this post hoc analysis, patients randomized to guselkumab were included and pooled (N = 493). Longitudinal trajectories of achieving each MDA criterion through week 100 were derived using non-responder imputation. Time to achieve each criterion was estimated with Kaplan-Meier analysis. Multivariate regression for time to achieve each criterion (Cox regression) and achievement at week 100 (logistic regression) was used to identify contributing factors.

RESULTS

Continuous improvement across all MDA domains was shown over time. ~70% of patients achieved near remission in swollen joint count (SJC), Psoriasis Area and Severity Index (PASI), and enthesitis through week 100. Median times to achieve individual criteria differed significantly (p < 0.0001), with SJC ≤ 1 (20 weeks), PASI ≤ 1 (16 weeks), and ≤ 1 tender entheses (16 weeks) being faster than patient-reported criteria (pain ≤ 15 mm, patient global assessment of arthritis and psoriasis ≤ 20 mm, Health Assessment Questionnaire-Disability Index ≤ 0.5) and tender joint count ≤ 1. Higher baseline domain scores, older age, worse fatigue, and increased body mass index were significant predictors of longer time to achieve minimal levels of disease activity assessed via patient-reported criteria.

CONCLUSIONS

Substantial proportions of guselkumab-treated patients achieved individual MDA criteria, each showing continuous improvement through week 100, although with distinct trajectories. Median times to achieve physician-assessed MDA criteria were significantly faster compared with patient-driven criteria. Identification of modifiable factors affecting the time to achieve patient-reported criteria has the potential to optimize the achievement and sustainability of MDA in the clinic via a multidisciplinary approach to managing PsA, involving both medical and lifestyle interventions.

TRIAL REGISTRATION NUMBER

NCT03158285.

TRIAL REGISTRATION DATE

May 16, 2017.

Treatment with Upadacitinib in Active Psoriatic Arthritis: Efficacy and Safety Data of the First 192 Patients from the UPJOINT Study, a Multicentre, Observational Study in Clinical Practice

INTRODUCTION

Our aim was to investigate the efficacy and safety of upadacitinib (UPA) in patients with either oligo- or polyarticular active psoriatic arthritis (PsA) using routine clinical practice data from an observational, prospective, multicentre study.

METHODS

This interim analysis contains upadacitinib efficacy and safety data from the UPJOINT study, collected from baseline to the week 24 visit with a focus on composite measures, clinical assessments and patient-reported outcomes, amongst others, including minimal disease activity (MDA), very low disease activity (VLDA), Disease Activity Index for Psoriatic Arthritis (DAPSA), Leeds Enthesitis Index (LEI), resolution of dactylitis and nail psoriasis and body surface area affected by skin psoriasis (BSA).

RESULTS

A total of 296 patients with baseline data and 192 with completed week 24 visits were included in the analysis. The proportion of patients achieving MDA increased from 2.7% at baseline to 39.1% at week 24 (95% CI 32.1, 46.3). Similarly, the number of patients in DAPSA remission (DAPSA ≤ 4) increased from 0 at baseline to 32 (16.7%) by week 24. At that time, 59.4% of the patients were either in DAPSA remission or had low disease activity (DAPSA ≤ 14). During the 24 weeks time frame, the proportion of patients with BSA ≤ 3 increased from 80.7% to 91.1%. Furthermore, at weeks 12 and 24, 45.14% and 47.19% of affected patients showed a resolution of enthesitis. Active dactylitis and nail psoriasis at baseline were reported to affect 10.5% and 22.0%, decreasing to 2.6% and 5.7% at week 24, respectively. The safety findings are consistent with the known safety profile of upadacitinib in rheumatoid arthritis and PsA; no new safety risks were identified.

CONCLUSION

The data from this study confirm the findings of previous randomized controlled trials suggesting UPA is an effective treatment for active PsA without any new safety signals in patients from daily clinical practice.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT04758117.

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.

Upadacitinib effectiveness and factors associated with minimal disease activity achievement in patients with psoriatic arthritis: preliminary data of a real-life multicenter study

BACKGROUND

Upadacitinib (UPA) is a selective JAK inhibitor recently approved for the treatment of psoriatic arthritis (PsA). In this post-approval study, we aimed to evaluate the effectiveness and safety of UPA over 24 weeks and identify clinical predictors of response, in a multicentric cohort of patients affected by PsA.

METHODS

One hundred and twenty-six patients with PsA treated with UPA were enrolled in 10 Italian centres. UPA effectiveness outcomes, such as the proportion of patients with MDA status, DAPSA remission, and low disease activity, ASDAS-CRP inactive and low disease activity, and change from baseline in DAPSA and ASDAS-CRP scores, were evaluated every 12 weeks until week 24. The proportion of DAPSA minor, moderate, and major improvement, and ASDAS clinically important improvement (CII) and major improvement (MI) were considered as well. All treatment-related adverse events were collected during the observation period. Clinical predictors of MDA response at week 24 were evaluated through multivariate analysis.

RESULTS

At baseline, 124/126 (98%) and 54/126 (43%) patients showed peripheral and axial involvement, respectively; 110 (87%) patients were intolerant or resistant to biologic DMARDs.  At 24 weeks, MDA status, DAPSA remission, and ASDAS-CRP inactive disease were achieved in 47%, 23%, and 48% of patients, respectively. Minor, moderate, and major DAPSA improvement was observed in 67%, 39%, and 23%, respectively; while 65% and 35% achieved ASDAS-CRP CII and MI, respectively. The mean change from baseline was 15.9 ± 13.5 (p < 0.001) for DAPSA and 1.21 ± 0.97 (p < 0.001) for ASDAS-CRP. Thirteen patients (10%) discontinued UPA due to a lack of efficacy or non-serious adverse events. No serious adverse events were observed. Male gender (OR 2.54, 95% CI 1.03-6.25 p = 0.043), being naïve to biological DMARDs (OR 4.13, 95% CI 1.34-12.71, p = 0.013) and elevated baseline CRP (OR 2.49, 95% CI 1.02-6.12, p = 0.046) were associated with MDA response at week 24.

CONCLUSIONS

This is one of the first real-life studies supporting the effectiveness of UPA and its safety profile in PsA patients. Furthermore, the study identifies predictors of MDA response to UPA treatment at 6 months.

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).

Serum Calprotectin as a Promising Inflammatory Biomarker in Psoriatic Arthritis: a 1-Year Longitudinal Study

INTRODUCTION

There are few biomarkers correlated with psoriatic arthritis (PsA). We aimed to explore the clinical value of calprotectin (CLP) in PsA in disease activity and treatment targets.

METHODS

Serum CLP was detected by enzyme-linked immunosorbent assay (ELISA) in 71 patients with PsA, 55 patients with psoriasis (PsO), and 10 healthy controls. The association of serum CLP with disease activity index at baseline and follow-up was analyzed. Cox regression and receiver operating characteristic (ROC) analysis were used to evaluate the potential of CLP for predicting the achievement of treatment targets, including low disease activity (LDA), remission, and minimal disease activity (MDA).

RESULTS

Serum CLP levels (μg/ml) were significantly increased in patients with PsA/PsO compared with healthy controls (p < 0.001). Serum CLP levels were positively associated with psoriasis area and severity index (PASI), disease activity in psoriatic arthritis (DAPSA), and its components [including tender joint count (TJC), swollen joint count (SJC), patient's global assessment (PGA), and visual analog scale (VAS)-pain, r 0.290-0.601, all p value < 0.05]. After 1-year follow-up, the number of patients with PsA in remission and MDA increased [17 (23.9%) versus 47 (66.1%) and 21 (29.5%) versus 52 (73.2%) respectively, all p value < 0.001]. Cox regression and Kaplan-Meier survival analysis indicated that patients with lower CLP obtain LDA, MDA, and remission earlier, including remission and MDA within a year (all p-value < 0.05). ROC analysis showed the ability of serum at baseline to predict the achievement of the treatment target in 3 months [area under the curve (AUC) 0.663-0.691, all p-values < 0.05].

CONCLUSIONS

Serum CLP level was correlated with disease activity in PsA. It also possessed the ability to predict the achievement of the therapeutic target. These features of CLP would make it a useful tool in clinical work.

Population Pharmacokinetics and Exposure-Response Analyses for Risankizumab in Patients with Active Psoriatic Arthritis

INTRODUCTION

Risankizumab is an anti-IL23 monoclonal antibody approved for the treatment of moderate to severe plaque psoriasis and active psoriatic arthritis (PsA). This work characterizes the pharmacokinetics of risankizumab in PsA compared with psoriasis and evaluates the efficacy and safety exposure-response relationships in PsA.

METHODS

The population pharmacokinetic analyses included data from 1527 participants that originated from one phase 1 healthy participant study, one phase 2 dose-ranging study in patients with PsA with an open-label extension study, and two pivotal phase 3 studies in patients with PsA, where the clinical regimen of risankizumab 150 mg administered subcutaneously (SC) at weeks 0, 4, and every 12 weeks thereafter was compared with placebo. Pharmacokinetics were analyzed using nonlinear mixed-effects modeling. Simulation analyses using the final model were conducted to evaluate the impact of covariates on exposure. Data from 1407 patients with PsA from the phase 3 studies were included in the exposure-response analyses. Graphical analyses were used to evaluate efficacy and safety exposure-response relationships, and logistic regression was conducted for further assessment of efficacy exposure-response relationships.

RESULTS

Risankizumab pharmacokinetics were well described by a two-compartment model with first-order SC absorption and elimination. None of the evaluated covariates showed clinically relevant impact on exposure. On the basis of the final model, systemic clearance, steady-state volume of distribution, and terminal phase elimination half-life were estimated to be ~ 0.31 L/day, 11.1 L, and 26.3 days, respectively, for a typical 90 kg patient with PsA. Absolute SC bioavailability was estimated to be 83.5%. Exposure-response quartile analyses suggested that exposures associated with the clinical regimen maximized efficacy across the endpoints evaluated. No exposure dependency was observed for key safety endpoints.

CONCLUSIONS

Risankizumab exhibited linear and time-independent pharmacokinetics in patients with PsA and was comparable to patients with plaque psoriasis. Efficacy and safety exposure-response analyses support that the clinical regimen achieved robust efficacy with a favorable safety profile for patients with active PsA.

CLINICAL TRIALS

NCT02596217, NCT02719171, NCT02986373, NCT03671148, and NCT03675308.

CLINICAL TRIALS

NCT02596217, NCT02719171, NCT02986373, NCT03671148, and NCT03675308.

Minimal disease activity (MDA) in patients with recent-onset psoriatic arthritis: predictive model based on machine learning

Background

Very few data are available on predictors of minimal disease activity (MDA) in patients with recent-onset psoriatic arthritis (PsA). Such data are crucial, since the therapeutic measures used to change the adverse course of PsA are more likely to succeed if we intervene early. In the present study, we used predictive models based on machine learning to detect variables associated with achieving MDA in patients with recent-onset PsA.

Methods

We performed a multicenter observational prospective study (2-year follow-up, regular annual visits). The study population comprised patients aged ≥18 years who fulfilled the CASPAR criteria and less than 2 years since the onset of symptoms. The dataset contained data for the independent variables from the baseline visit and from follow-up visit number 1. These were matched with the outcome measures from follow-up visits 1 and 2, respectively. We trained a random forest–type machine learning algorithm to analyze the association between the outcome measure and the variables selected in the bivariate analysis. In order to understand how the model uses the variables to make its predictions, we applied the SHAP technique. We used a confusion matrix to visualize the performance of the model.

Results

The sample comprised 158 patients. 55.5% and 58.3% of the patients had MDA at the first and second follow-up visit, respectively. In our model, the variables with the greatest predictive ability were global pain, impact of the disease (PsAID), patient global assessment of disease, and physical function (HAQ-Disability Index). The percentage of hits in the confusion matrix was 85.94%.

Conclusions

A key objective in the management of PsA should be control of pain, which is not always associated with inflammatory burden, and the establishment of measures to better control the various domains of PsA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02838-2.

Residual Disease Associated with Suboptimal Treatment Response in Patients with Psoriatic Arthritis: A Systematic Review of Real-World Evidence

Objective

This systematic literature review aimed to identify and summarise real-world observational studies reporting the type, prevalence and/or severity of residual symptoms and disease in adults with psoriatic arthritis (PsA) who have received treatment and been assessed against remission or low disease activity targets.

Methods

Patients had received treatment and been assessed with treat-to-target metrics, including minimal disease activity (MDA), Disease Activity Index in PsA (DAPSA) and others. MEDLINE, Embase® and the Cochrane Database of Systematic Reviews (CDSR) were searched using search terms for PsA, treatment targets and observational studies. Screening of search results was completed by two independent reviewers; studies were included if they reported relevant residual disease outcomes in adults with PsA who had received one or more pharmacological treatments for PsA in a real-world setting. Non-observational studies were excluded. Information from included studies was extracted into a prespecified grid by a single reviewer and checked by a second reviewer.

Results

Database searching yielded 2328 articles, of which 42 publications (27 unique studies) were included in this systematic literature review. Twenty-three studies reported outcomes for MDA-assessed patients, and 14 studies reported outcomes for DAPSA-assessed patients. Physician- and patient-reported residual disease was less frequent and/or severe in patients reaching targets, but often not absent, including when patients achieved very low disease activity (VLDA) or remission. For example, studies reported that 0–8% patients in remission according to DAPSA (or clinical DAPSA) had > 1 tender joint, 25–39% had Psoriasis Area and Severity Index (PASI) score > 1 and 0–10% had patient-reported pain > 15. Residual disease was usually less frequent and/or severe among patients achieving MDA-assessed targets versus DAPSA-­assessed targets, especially for skin outcomes.

Conclusion

The findings demonstrate a need for further optimisation of care for patients with PsA.

Quantification of pre-existing radiographic damage and its relationship with joint activity and long-term clinical outcomes with secukinumab therapy in patients with psoriatic arthritis

BACKGROUND

Psoriatic arthritis (PsA) patient data from two phase 3 secukinumab trials (FUTURE 1, 5) were analysed to quantify the prevalence and extent of pre-existing radiographic damage (RD) at baseline; investigate the association of RD with swollen/tender joint counts (SJC/TJC) at baseline; and investigate the extent to which RD at baseline correlated with response to secukinumab.

METHODS

Pooled data (N = 1554) provided baseline radiographic bone erosion and joint space narrowing (JSN) scores at pre-specified locations per the van der Heijde-modified total Sharp score (vdH-mTSS) for PsA and swollen and tender joint scores in the same joints at multiple visits. Overall patient RD and individual joints RD bone erosion and JSN scores were assessed. The association between joint activity (tenderness, swelling) and vdH-mTSS was assessed at the overall patient-level and individual joint tender, swollen scores (yes/no) and RD joint JSN and bone erosion scores at the individual joint-level. Treatment response was assessed using SJC/TJC at weeks 16 and 52 and the proportion of patients achieving minimal disease activity (MDA) over all assessments within 1 year from FUTURE 5 alone.

RESULTS

A substantial prevalence of pre-existing RD with higher prevalence of erosion than JSN was observed (86% and 60% of patients had positive erosion and JSN scores, respectively); higher RD prevalence was associated with longer time since PsA diagnosis. Joint activity was weakly associated with RD at baseline at the patient-level (Pearson's coefficients: range 0.12-0.18), but strongly associated at the individual joint-level, with a higher probability of tender/swollen joints to associate with higher JSN/erosion scores: all 42 analysed joints showed statistical significance at the 0.05 level (unadjusted) for the relationship between joint tenderness (yes/no) and its JSN score, all but one for tenderness and bone erosion scores, and all but 2 for swollen and JSN scores and for swollen and bone erosion score. Secukinumab (150/300 mg), reduced TJC and SJC across all values of baseline erosion and JSN scores at weeks 16 and 52. Patients with higher levels of RD were less likely to achieve zero tender/zero swollen joint status and had lower chance of achieving MDA.

CONCLUSIONS

PsA patients showed substantial prevalence of RD at baseline that correlated with time since diagnosis, but patient's individual joint activity was strongly associated with pre-existing RD at those joints. Patients with the highest RD at baseline had a reduced likelihood of achieving zero joint count status.

The "Climb" Towards Minimal Disease Activity in Psoriatic Arthritis

Introduction

Minimal disease activity (MDA) is a validated outcome measure in psoriatic arthritis (PsA) defining a low disease activity state with a cutoff of 5/7. The main aim of the study was to look at the MDA divided into in the seven cutoffs, analyzing the more frequently achieved domains. The relationship between MDA, PASS, PsAID, DAPSA, and the PhGA in all cutoffs was also evaluated.

Methods

Cross-sectional analysis on PsA patients satisfying CASPAR criteria. An assessment of disease activity, treatment target, function, and impact of disease was performed. Patients achieving MDA were compared to patients not achieving MDA in order to evaluate the most frequent domain found.

Results

Ninety-three PsA patients were enrolled. MDA was satisfied in 44/93, while in 47 MDA ranged from 1/7 to 4/7. Among the seven domains, Leeds Enthesitis Index (LEI) was the most frequent domain found in all patients. In those not in MDA, BSA ≤ 3 (70%) and swollen joints count ≤ 1 (68%) were also well represented. The domains with a lower percentage of patients not in MDA were HAQ-DI ≤ 0.5 (38.8%), tender joint count ≤ 1 (23%), PtGA ≤ 20 (4.2%) and VAS pain ≤ 15 mm (2%). There was a growing trend, from MDA 1/7 to MDA 7/7 in the percentage of patients in PASS yes, in PsAID ≤ 4, and in DAPSA ≤ 14.

Conclusions

The present study detailed the domains more achieved also in those patients not in MDA showing that “physician-driven” domains are more frequently achieved in our patients.

Relationships between psoriatic arthritis composite measures of disease activity with patient-reported outcomes in phase 3 studies of tofacitinib

Background

In psoriatic arthritis (PsA), further understanding of the relationships between clinical measures and patient-reported outcomes (PROs) is needed. This post hoc analysis evaluated associations between minimal disease activity (MDA) as a continuous outcome (termed ScoreMDA) or Psoriatic Arthritis Disease Activity Score (PASDAS) with selected PROs not included in the composite measures.

Methods

Data from two phase 3 studies of tofacitinib in PsA (OPAL Broaden [NCT01877668; N = 422]; OPAL Beyond [NCT01882439; N = 394]) were included. MDA (binary outcome) was defined as meeting ≥5/7 criteria. For ScoreMDA, each criterion was assigned a value (1 = true; 0 = false; score range, 0–7; scores ≥5 indicated MDA). For PASDAS (score range, 0–10), higher scores indicated worse disease activity. PROs analyzed included Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Patient’s Assessment of Arthritis Pain visual analog scale (Pain VAS), and EuroQoL-Five Dimensions-Three Level Health Questionnaire visual analog scale (EQ-5D-3L VAS) and utility index. Relationships were evaluated using repeated measures regression models.

Results

Similar, approximately linear relationships were confirmed between PASDAS or ScoreMDA and PROs in both studies. In OPAL Broaden and OPAL Beyond, a one-point difference in PASDAS was associated with clinically relevant differences in PROs, including EQ-5D-3L VAS (− 6.7 mm, − 6.9 mm), Pain VAS (9.9 mm, 10.7 mm), and FACIT-F (− 2.8, − 3.3). A one-point difference in ScoreMDA was associated with clinically relevant differences in PROs, including EQ-5D-3L VAS (5.0 mm, 5.5 mm) and FACIT-F (1.9, 2.7) in OPAL Broaden and OPAL Beyond, respectively.

Conclusions

Linear associations between PASDAS or ScoreMDA and PROs provide interpretable and quantifiable metrics between composite clinical measures and PROs, highlighting the importance of these measures in understanding the relevance of treat-to-target goals in PsA.

Trial registration

ClinicalTrials.gov, NCT01877668. Registered on June 12, 2013. ClinicalTrials.gov, NCT01882439. Registered on June 18, 2013

Patient characteristics and minimal disease activity in psoriatic arthritis: a transcontinental comparison

Psoriatic arthritis (PsA) is a heterogeneous disease with both environmental and genetic factors playing a role in this diversity. The aim of this study is to compare the patient profiles and outcomes in PsA patients in three countries from three continents. PsA patients from Turkey (n = 184), Canada (n = 200), and Italy (n = 177) from the Psoriatic Arthritis-International Database (PsArt-ID) were compared for patient demographics, disease features, treatments, and minimal disease activity (MDA) rates. Patient profiles were different across countries, patients from Italy being older [median (Q1-Q3): 59 (51-65)] than patients from Turkey [48 (37-58)] and Canada [55 (44-65)] and Italian patients having more frequent comorbidities and being more frequently smokers. For disease phenotypes, patients from Italy had axial disease less frequently (12%) than others (Turkey 23%, Canada 52%). Similarly, disease activity in patients from Italy was higher with higher tender and swollen joint counts and body surface area for psoriasis. The lowest rate of biologic use was observed in Italy [ Italy: 18.4%, Turkey: 26.1%, Canada: 33.9%]. MDA was achieved more in Canada [OR (CI): Canada vs Italy = 3.326 (1.983-5.577); Canada vs Turkey = 2.392 (1.498-3.818); Turkey vs Italy = 1.391 (0.786-2.460)]. PsA patient characteristics differ across countries which may be leading to differences in treatments and MDA rates. The differences can be a combination of genetic or geographical differences as well as the demographics of the general population in that area. Therefore, the unmet needs of PsA patients may vary globally. Key Points • PsA disease characteristics, phenotypes, activity levels and treatments differ across countries. • Unmet needs of PsA need to be determined individually.

Validation and clinical interpretability of PsAID - psoriatic arthritis impact of disease

BACKGROUND

Psoriatic arthritis (PsA) is a chronic inflammatory disease of widely varying presentation, which determines functional and psychological impairment, with a high negative impact on patients' quality of life. Therefore, knowing the patient's perception of their health status is of fundamental importance for understanding the real impact of PsA. Given this context, the European League Against Rheumatism (EULAR) recently developed the Psoriatic Arthritis Impact of Disease (PsAID) - instrument to specifically assess the impact of PsA for the patient.

OBJECTIVE

Validate the brazilian portuguese version of PsAID-12 (Psoriatic Arthritis Impact of Disease) and to verify its interpretability in clinical practice, through its relation with measures of psoriatic arthritis activity.

METHODS

A multicenter cross-sectional study, which recruited 160 patients, who met the Classification criteria for Psoriatic Arthritis (CASPAR), in six Brazilian centers of rheumatology. Reliability was assessed by Cronbach's alpha coefficient and by the intraclass correlation coefficient (ICC). The construct validity was evaluated by exploratory factorial analysis and also by Spearman correlation with other PROMs and measures of disease activity evaluation.

RESULTS

Of the total number of participants, 50% were female, with a mean age (SD) of 54.0 ± 11.2 years; 68% had only peripheral arthritis and 32% had pure or mixed axial involvement. The majority (67.7%) of the patients were using biological treatment. The reliability of internal consistency (alpha-Cronbach = 0.93) and test-retest (ICC = 0.996) were good. Factor analysis revealed two factors, named physical and psychosocial, which included the skin evaluation item. PsAID-12 correlated significantly with other PROMs, demonstrating good construct validity. PsAID-12 was also significantly associated with the disease activity assessment instruments (DAS28-ESR, ASDAS, and BASDAI) and the MDA status: "Minimum Disease Activity". Fibromyalgia did not significantly affect the final PsAID-12 score.

CONCLUSION

The brazilian version of PsAID-12 has been shown to be a reliable and valid measure of the impact of the disease in patients with psoriatic arthritis. Moreover, it associated significantly with the scores of disease activity assessment.

[Treatment of psoriatic arthritis : Are there differential indications?]

Psoriatic arthritis (PsA) is a very heterogeneous immune-mediated disease that usually involves skin and joints but can also affect entheses and extra-articular structures during the disease course. Furthermore, it can also be linked with other associated diseases. Therefore, the individualized selection of an effective and patient-oriented treatment must be carried out taking the extent of various manifestations of the PsA itself and also of other influencing factors into consideration. Various recommendations for selection and control of the suitable treatment of PsA are available for clinical use. The recommendations of the European League Against Rheumatism (EULAR) and the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) are the two recommendations that are frequently used and internationally acknowledged. Both recommendations were updated in 2016. Specific German treatment recommendations are currently missing. In analogy to the treat-to-target strategy for rheumatoid arthritis, at least minimal disease activity (MDA) should be achieved in PsA patients with the use of specific therapeutic interventions if remission as the maximum therapeutic goal cannot be reached. New treatment options, which target different specific molecules, offer possibilities for a more differentiated personalized medicinal treatment for improvement of the care of PsA patients. This particularly applies to a focus on personalized strategies for optimal treatment of various manifestation forms and patterns.

Partially hidden multi-state modelling of a prolonged disease state defined by a composite outcome

For rheumatic diseases, Minimal Disease Activity (MDA) is usually defined as a composite outcome which is a function of several individual outcomes describing symptoms or quality of life. There is ever increasing interest in MDA but relatively little has been done to characterise the pattern of MDA over time. Motivated by the aim of improving the modelling of MDA in psoriatic arthritis, the use of a two-state model to estimate characteristics of the MDA process is illustrated when there is particular interest in prolonged periods of MDA. Because not all outcomes necessary to define MDA are measured at all clinic visits, a partially hidden multi-state model with latent states is used. The defining outcomes are modelled as conditionally independent given these latent states, enabling information from all visits, even those with missing data on some variables, to be used. Data from the Toronto Psoriatic Arthritis Clinic are analysed to demonstrate improvements in accuracy and precision from the inclusion of data from visits with incomplete information on MDA. An additional benefit of this model is that it can be extended to incorporate explanatory variables, which allows process characteristics to be compared between groups. In the example, the effect of explanatory variables, modelled through the use of relative risks, is also summarised in a potentially more clinically meaningful manner by comparing times in states, and probabilities of visiting states, between patient groups.

Exploration of the Product of the 5-Point Investigator's Global Assessment and Body Surface Area (IGA × BSA) as a Practical Minimal Disease Activity Goal in Patients with Moderate-to-Severe Psoriasis

BACKGROUND/AIMS

In the treat-to-target era, psoriasis disease activity measures that can be easily performed in routine clinical practice are needed. This retrospective pooled analysis explored cutoff values of the product of the 5-point Investigator's Global Assessment and percentage of affected body surface area (IGA × BSA) correlating with achievement of minimal disease activity (MDA).

METHODS

Post hoc analysis of the phase 3 clinical trials ERASURE, FIXTURE, FEATURE, and JUNCTURE was conducted to determine associations between IGA × BSA and 2 MDA definitions (Psoriasis Area and Severity Index [PASI] 90 and Dermatology Life Quality Index [DLQI] 0/1, or PASI score ≤1 or BSA <3%) in patients with moderate-to-severe psoriasis receiving secukinumab 300 mg. For each definition of MDA, a range of possible cutoff values of IGA × BSA was examined at each time point. The optimal cutoff value was determined using Youden index (YI), calculated as (sensitivity + specificity - 1).

RESULTS

For MDA defined as PASI 90 and DLQI 0/1, optimal IGA × BSA cutoffs were 2.10 at week 12 (YI, 0.60; sensitivity, 0.78; specificity, 0.82), 1.02 at week 24 (YI, 0.55; sensitivity, 0.73; specificity, 0.82), and 1.00 at week 52 (YI, 0.65; sensitivity, 0.79; specificity, 0.86). For MDA defined as PASI score ≤1 or BSA <3%, optimal IGA × BSA cutoffs were 2.98 at week 12 (YI, 0.91; sensitivity, 0.99; specificity, 0.92), 2.80 at week 24 (YI, 0.94; sensitivity, 0.99; specificity, 0.95), and 3.00 at week 52 (YI, 0.96; sensitivity, 1.00; specificity, 0.96).

CONCLUSION

IGA × BSA could be a valid measure highly associated with achievement of MDA.

A novel role for the psoriatic arthritis impact of disease (PsAID) questionnaire

BACKGROUND

The Minimal Disease Activity (MDA) uses the Health Assessment Questionnaire (HAQ) as one criterion. HAQ does not correlate well with disease activity with increased PsA disease duration, and its use in the MDA has been questioned. The Psoriatic Arthritis Impact of Disease (PsAID) was specifically developed for PsA Patients. We aimed to validate the PsAID within our patient cohort and determine if the PsAID can replace the HAQ in the MDA.

METHODS

Patients were recruited from the PsA clinic and assessed according to a standard protocol including demographics, clinical features and laboratory tests. Descriptive statistics were calculated. PsAID cut-offs for use in the MDA were generated based on the Clinical Disease Activity for Psoriatic Arthritis (cDAPSA).

RESULTS

115 patients completed the PsAID. There were 70 males, 45 females, with a mean PsA duration of 18.7 (±11.6) years. Mean scores of PsAID-9 and PsAID-12 were 3.4 (±2.4) and 3.2 (±2.3), respectively. The PsAID correlated moderately well with 9 of the PROMs administered in the clinic (ρ = 0.51-0.78). Four PsAID cutoffs based on cDAPSA were generated for use in the MDA: remission (REM) PsAID-9, REM PsAID-12, low disease activity (LDA) PsAID-9, and LDA PsAID-12. All four versions of the PsAID MDAs had sensitivity greater than 85% with the HAQ-MDA, and three versions of the PsAID-MDA had specificity greater than 85% with the HAQ-MDA.

CONCLUSIONS

The high sensitivity and specificity of the PsAID-MDA with the HAQ-MDA suggest that the PsAID is an effective replacement for the HAQ in the MDA.

Unmet Needs in the Field of Psoriasis: Pathogenesis and Treatment

In times of targeted therapies, innovative therapeutics become tools to further unravel the pathogenesis of the treated disease, thus influencing current pathogenetic concepts. Based on such paradigm shifts, the next generation of novel therapeutic targets might be identified. Psoriasis is a good example for the resulting most fruitful dialog between clinical and fundamental research. As a result of this, the key role of Th17 lymphocytes, some of their effector molecules, as well as mediators contributing to their maturation have been identified, many of these being targeted by some of the most effective drugs currently available to treat psoriasis. During this process, it became obvious that major parts of the puzzle remain yet to be uncovered or understood in much more detail. This review will therefore address the search for additional important effector cells other than Th17 lymphocytes, such as neutrophils, monocytes, and mast cells, mediators other than IL-17A, including some other IL-17 isoforms, and trigger factors such as potential autoantigens. This will lead to discussing the next generation of targeted therapies for psoriasis as well as treatment goals. These goals need to comprise both psoriasis as well as its comorbidities, as a comprehensive approach to manage the whole patient with all his health issues is urgently needed. Finally, given the substantial differences in resources available in different parts of the world, the global burden of psoriasis and options on how to care for patients outside developed countries will be assessed.

Time to minimal disease activity in relation to quality of life, productivity, and radiographic damage 1 year after diagnosis in psoriatic arthritis

Background

In a cohort of patients with newly diagnosed psoriatic arthritis (PsA) who received usual care, we investigated the impact of time elapsed to minimal disease activity (MDA) on health-related quality of life (HRQoL), work productivity, and radiographic damage throughout the first year after diagnosis.

Methods

Data collected in the Dutch southwest early PsA cohort (DEPAR) study were analyzed. These three-monthly data encompassed disease activity, HRQOL was measured with the Short Form 36 (SF36) Physical Component Scale (SF36-PCS) and Mental Component Scale, and productivity was measured with the Productivity Cost Questionnaire. Radiographic damage was scored at baseline and at 12 months with the PsA-modified Sharp/van der Heijde score. Patients were classified by time to MDA as in early (within 3 months), late (at 6–12 months), and never MDA in the first year.

Results

We included 296 patients who had had their 1-year outpatient visit (mean age 51 years, 53% male). Ninety-six (32%) were classified as early MDA, 78 (26%) as late MDA, and 98 (33%) as never MDA. Data of 24 patients (8%) were missing. SF36-PCS and productivity scores improved after gaining MDA, but remained low in never MDA patients. At 1 year, SF36-PCS and productivity scores were similar in early and late MDA patients. Radiographic progression rate was low and similar in all groups.

Conclusion

Gaining MDA was associated with considerable improvement in HRQoL and functioning, irrespective of time to first MDA. In the one third of patients not in MDA in the first year, the disease had a substantial health impact.

Treating psoriatic arthritis to target: discordance between physicians and patients' assessment, non-adherence, and restricted access to drugs precluded therapy escalation in a real-world cohort

The treat-to-target strategy (T2T) was associated with better outcomes in psoriatic arthritis (PsA) compared to standard care in clinical trials. This study aimed to analyze factors precluding treatment optimization in a T2T strategy conducted in a real-world cohort of PsA patients. A retrospective cross-sectional study nested in a cohort was conducted. Medical records of patients ≥ 18 years old, fulfilling CASPAR criteria and with at least one visit in the PsA clinic, were reviewed. Demographic data, current medication, and minimal disease activity (MDA) criteria were recorded. Reasons for the non-escalation of therapy in patients who were not classified as MDA were reported as absolute and relative frequencies. In the 8-month period, 131 visits (corresponding to 74 patients) were conducted. The MDA criteria were available in 113 visits (86.3%) and patients were classified as MDA in 31.0% of the visits (N = 35/113). Although in 69.0% of the visits patients were not in MDA, (N = 78/113), therapy was adjusted in only 42.3% (N = 33/78). Reasons precluding treatment escalation in non-MDA subjects were physician's impression of remission (57.7%, N = 26), non-adherence to previous prescription (17.8%, N = 8), restricted access to drugs (17.8%, N = 8), adverse events (11.1%, N = 5), poor understanding of medication instructions (6.7%, N = 3), patient's refusal to escalate therapy (4.4%, N = 2), and recent change in therapy (2.2%, N = 1). Discordance between the physician's clinical evaluation and the MDA criteria, non-adherence to prescription, and poor access to drugs were the main factors precluding escalation of therapy in a T2T strategy in a real-world PsA cohort.

Novel Concepts in Psoriatic Arthritis Management: Can We Treat to Target?

PURPOSE OF REVIEW

Psoriatic arthritis (PsA) is a chronic inflammatory spondyloarthritis that can cause progressive joint damage and irreversible disability. Advances in modern therapies, now mean a target of remission is an achievable goal in PsA. There is strong and consistent evidence that a treat-to-target (T2T) approach to PsA management results in better patient outcomes; however, the practicalities of incorporating this strategy into routine clinical practice remain a challenge. The heterogeneous nature of this condition and the need for validated outcome measures have to-date hampered consensus on a definition of remission. This review aims to summarise the current T2T research landscape in PsA and highlight potential roles for biomarkers and imaging advances in revolutionising the T2T concept.

RECENT FINDINGS

There is a growing body of evidence to support the implementation of a T2T strategy, using a pre-defined target in PsA management, with significant benefits in disease outcome, physical function and quality of life. Whilst remission is the ultimately goal for PsA patients and their clinicians, further comparative studies of different treatment targets are needed to establish a widely acceptable definition of remission.

Achieving minimal disease activity in psoriatic arthritis predicts meaningful improvements in patients' health-related quality of life and productivity

Background

Although psoriatic arthritis is complex and involves multiple domains, recent advances in treatments have made remission or near-remission of most symptoms a potentially achievable goal for many patients. We sought to evaluate whether achieving minimal disease activity (MDA) criteria represented meaningful improvement from the patient perspective.

Methods

Data were combined from two randomized, multinational, 24 week clinical studies of ixekizumab, a high-affinity monoclonal antibody selectively targeting interleukin-17A, in biological drug-naïve or experienced adults. MDA required 5 of 7 of: tender joint count ≤1; swollen joint count ≤1; Psoriasis Area and Severity Index total score ≤ 1 or body surface area ≤ 3%; patient’s assessment of pain visual analogue scale (VAS) ≤15; patient’s global assessment of disease activity VAS ≤20; Health Assessment Questionnaire Disability Index ≤0.5; and tender entheseal points ≤ 1. MDA responders and non-responders were compared for mean change from baseline on the 36-Item Short Form Health Survey (SF-36), European Quality of Life 5 Dimension 5 Level Health Questionnaire (EQ-5D-5 L); EQ-5D-5 L VAS; and Work Productivity and Activity Impairment–Specific Health Problem (WPAI-SHP) questionnaire.

Results

MDA responders had significantly greater improvements versus non-responders in each SF-36 domain and in the SF-36 physical summary score; improvements were also greater in the EQ-5D-5 L and EQ-5D-5 L VAS, and in 3 of the 4 WPAI-SHP domains. MDA responders were more likely to achieve minimal clinically important differences than non-responders.

Conclusion

These findings support MDA response as being strongly associated with achieving improved disease status based on measures of patient reported health-related quality of life and productivity.

Trial registration

SPIRIT-P1, NCT01695239, First Posted: September 27, 2012; and SPIRIT-P2, NCT02349295, First Posted: January 28, 2015.

Electronic supplementary material

The online version of this article (10.1186/s41927-018-0030-y) contains supplementary material, which is available to authorized users.

Considerations for the definition of remission criteria in psoriatic arthritis

OBJECTIVES

Psoriatic arthritis (PsA) is an autoimmune disease that can cause progressive structural damage of the joints and irreversible disability. The potentially achievable results of biologic therapy for PsA has led to the view that disease remission should be the goal of treatment. However, the heterogeneity of disease manifestations and need for validated outcome measures makes defining remission in PsA challenging. This article evaluates proposed criteria for defining remission in PsA and discusses how these criteria can be applied in clinical practice.

METHODS

A primary literature search was conducted in PubMed to identify articles discussing potential PsA treatment goals or targets, including minimal disease activity. English-language publications from the last 10 years were included in this assessment.

RESULTS

There are 5 clinical domains in PsA that must be considered when evaluating remission: synovitis, enthesitis, dactylitis, spondylitis, and psoriasis/nail psoriasis. Due to variability in the completeness of remission and time to achieve remission with different therapies between these domains, remission should be measured clinically through a combination of objective measures, or a composite assessment tool. Composite measures are more efficient than unidimensional instruments in measuring remission, but remission rates differ between the available composite indices.

CONCLUSION

Although the concept of remission as a treatment goal in PsA is gaining acceptance among rheumatologists, further work is necessary to develop a broadly acceptable definition of remission.

The GOLMePsA study protocol: an investigator-initiated, double-blind, parallel-group, randomised, controlled trial of GOLimumab and methotrexate versus methotrexate in early diagnosed psoriatic arthritis using clinical and whole body MRI outcomes

Background

Psoriatic arthritis (PsA) is a chronic inflammatory arthritis which impacts significantly on the quality of life and work capacity of affected individuals. Recent evidence has shown that early control of inflammation in PsA leads to improved long-term outcomes. It is postulated that prompt intervention after diagnosis using a remission-induction treatment strategy will lead to improved outcomes and optimal disease control of PsA.

The aim of the present study was to compare the clinical efficacy of a treatment strategy in newly diagnosed, treatment naïve PsA subjects, using the combination of golimumab (GOL), methotrexate (MTX) and steroids versus standard care (MTX monotherapy plus steroids).

Methods/design

GOLMePsA is an investigator initiated, phase IIIb, single-centre, randomised, double-blind, placebo-controlled, two-armed, parallel-group, imaging-supplemented study. Eighty-eight PsA patients, diagnosed within 24 months prior to screening and treatment naïve, will be randomised at baseline to receive: (arm 1) the combination of intramuscular/intra-articular prednisolone, MTX and GOL or (arm 2) the combination of intramuscular/intra-articular prednisolone, MTX and placebo for 24 weeks (interventional period). Primary outcome measure is clinical improvement (at least 1 unit difference) in the Psoriatic ArthritiS Disease Activity Score (PASDAS) composite index.

Reflecting a “step down” therapeutic approach, all participants successfully completing the interventional period will be followed up for a further 28 weeks. During this observational period, stable maintenance MTX monotherapy will continue for both arms, unless in case of intolerance or PsA relapse. In the latter case, additional treatment will be provided. Overall, the GOLMePsA study length is planned to be 52 weeks.

Discussion

The hypothesis underlining this study is that very early treatment with first-line GOL reduces disease activity in PsA, in comparison to conventional therapy.

Trial registration

EudraCT 2013–004122-28. 24/09/2013.

[Psoriatic arthritis : Current therapeutic standards]

Psoriatic arthritis (PsA) is a heterogeneous immune-mediated disease that usually involves the skin and joints but can also affect the entheses, spine and other extra-articular structures. Furthermore, it can be coupled with associated comorbidities. The selection of a patient-oriented and effective therapy is based on the extent of various manifestations of the disease as well as further influencing factors. Various recommendations for selection and control are available for deciding on a suitable treatment. The recommendations of the European League Against Rheumatism (EULAR) and the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) are most frequently used and are internationally acknowledged. Both recommendations were updated in 2016. German treatment recommendations are currently lacking. In analogy to the treat-to-target strategy in the treatment of rheumatoid arthritis, minimal disease activity should at least be achieved with the therapeutic intervention used if remission as the therapeutic target cannot be reached. New treatment options, which target different molecules, provide possibilities for a more differentiated therapy for improvement in the treatment of PsA patients.

Minimal disease activity and impact of disease in psoriatic arthritis: a Spanish cross-sectional multicenter study

BACKGROUND

Patients with psoriatic arthritis (PsA) experience functional impairment and reduced quality of life, and thus patient global assessment in PsA is explained mainly by the physical, but also by the psychological, aspect of the disease. To assess the prevalence of minimal disease activity (MDA) in Spanish patients with PsA, we examined their characteristics and the association between MDA and the impact of the disease as assessed by the PsA Impact of Disease (PsAID) questionnaire.

METHODS

A cross-sectional multicenter study was carried out in patients who fulfilled the Classification for Psoriatic Arthritis (CASPAR) criteria with at least 1 year of disease duration, and who were treated with biological or conventional synthetic (cs) disease-modifying anti-rheumatic drugs (DMARDs) according to routine clinical practice in Spain. Patients were considered in MDA if they met at least 5/7 of the MDA criteria. The association between MDA and the recently developed PsAID questionnaire was also recorded.

RESULTS

Of 227 patients included, 133 (58.6%) were in the MDA state (52% with antitumor necrosis factor (anti-TNF)α monotherapy, 24% with csDMARD monotherapy, and 24% with anti-TNFα in combination with csDMARD). Using multivariate logistic regression analysis, male gender (odds ratio (OR) 2.74, p = 0.001), a sedentary lifestyle (OR 3.13, p = 0.002), familial history of PsA (OR 0.38, p = 0.036), C-reactive protein (CRP) level (OR 0.92, p = 0.010), and use of corticoids (OR 0.33, p = 0.007) were considered features related to MDA. MDA patients had a significantly lower impact of the disease according to PsAID (mean total score (SD): MDA 3.3 (3.1) vs. non-MDA 7.1 (5.2); p < 0.001).

CONCLUSIONS

Nearly 60% of Spanish PsA patients achieve MDA in routine clinical practice. MDA remains one of the most useful therapeutic targets for PsA since patients who reached this state also had a significantly lower impact of disease according to PsAID.

The impact of concomitant diffuse idiopathic skeletal hyperostosis on the achievement of minimal disease activity in subjects with psoriatic arthritis

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by ossification of different entheses. Psoriatic arthritis (PsA) is a seronegative spondyloarthritis associated with psoriasis. Given the possible overlap of the two diseases, we assessed whether DISH presence may affect PsA clinical outcomes. Also, predictors of DISH presence in the cohort were investigated. Consecutive PsA patients from two Italian Rheumatology Research Units were enrolled. Subjects were splitted into two groups, according to the current treatment (TNF-α blockers or traditional DMARDs). All patients underwent a rheumatologic examination, blood sample collections and spine radiographs. Information about traditional vascular risk factors was recorded. In each patient, the presence of minimal disease activity was evaluated and the presence of DISH was established according to the Resnick and Niwayama criteria. Among the 80 enrolled subjects (57.5 % men, mean age 56.5 ± 11.1 years), the overall prevalence of DISH was 30.0 %. Patients with DISH were older, with higher BMI and waist circumference. DISH subjects showed worsen BASMI, HAQ and ESR. In a multivariate regression model, BASMI was a significant predictor of DISH presence (OR 3.027, 95 % CI 1.449-6.325, p = 0.003). The prevalence of MDA was lower in DISH patients than in no-DISH (16.7 vs 41.1 %, p = 0.041), and the presence of DISH was a predictor of not achieving MDA (OR 3.485, 95 % CI 1.051-11.550, p = 0.041). PsA subjects with DISH showed worsen indices of spine mobility and articular function and lower prevalence of minimal disease activity than no-DISH patients.