A majority of patients with psoriatic arthritis had persistent disease despite having regular rheumatology care, a Dutch study found.
Among a cohort of 142 patients seen in two clinics in Amsterdam from 2014 to 2015, two-thirds were considered by their treating rheumatologist as having persistent disease — yet in only 23% was treatment modified, according to Leonieke J.J. van Mens, MD, of the University of Amsterdam, and colleagues.
This was despite the fact that a randomized trial known as TICOPA demonstrated that a treat-to-target approach in psoriatic arthritis showed “significantly better outcomes in peripheral arthritis, skin, and patient-reported outcomes in comparison with the standard-care arm, with more patients reaching a minimal disease activity state in the treat-to-target arm,” they wrote online in Arthritis Research & Therapy.
Data on real-world treatment of psoriatic arthritis are sparse, and the few reports available have suggested that limited numbers of patients achieve a state of minimal disease activity.
Therefore, to examine the frequency of persistent disease and the reasons for this in usual care of psoriatic arthritis, van Mens and colleagues conducted a cross-sectional study of consecutive adult patients seen in their outpatient centers.
At clinic visits, treating rheumatologists performed physical examinations and rated disease activity on visual analog scales. They also were asked by the researchers if the patient appeared to have persistent disease, whether treatment would be modified, and if yes, what the change would be and if no, what the reason was.
Among the 90 patients considered to have residual disease, 31% had at least one swollen joint and 16% had at least three, 60% had at least one tender joint, 18% had enthesitis, 9% had dactylitis, and 30% had skin scores above 2 on a 0-10 scale.
A total of 46% were rated as having moderate or high disease activity, with most activity involving the joints and reports of pain rather than the skin.
The researchers found no differences in demographics or clinical features among those with and without persisting disease, but residual disease was seen more commonly among patients being treated only with conventional disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate (66%), and among those receiving a second tumor necrosis factor (TNF) inhibitor (69%) compared with those on a first TNF inhibitor (44%, P=0.019).
Treatment adjustments that were made included initiation of analgesics in six patients, local or intramuscular steroid injections in five, change from one conventional DMARD to another in four, initiation of a second or third TNF inhibitor in two, referral to another specialist in two, addition of a conventional DMARD to ongoing anti-TNF treatment in one, and start of a TNF inhibitor in one patient taking only a conventional DMARD.
In 57% of the patients whose treatment was not modified, the treating rheumatologist suggested that the problem was “minor,” even for patients with more than one swollen or tender joint. Other reasons included patient preference in 14%, nonadherence or adverse events in 7%, a lack of other treatment options in 7%, and various other reasons in a few others.
“Overall, judgment by the rheumatologist and/or patient rather than objective hurdles to intensify treatment (absence of additional treatment options, lack of compliance, intolerance) drove the decision not to modify treatment despite the presence of residual disease activity,” the researchers noted.
They also pointed out that a large number of patients with residual disease were being treated only with conventional DMARDs, and among those patients, “the addition of a TNF inhibitor was at that time a very obvious, well-validated, and recommended therapeutic alternative, which was not used despite ongoing disease activity.”
In addition, they emphasized that in the Netherlands, conventional DMARDs and TNF inhibitors are reimbursed for all patients with active disease if prescribed by rheumatologists, so cost would not have been the reason for failure to modify treatment.
One factor that may have contributed to the common failure to modify treatment may have been the lack of a structured approach and comprehensive measures of disease assessment for psoriatic arthritis. In addition, clinicians may not have been aware of the data demonstrating the improved outcomes with the treat-to-target approach, with the TICOPA study results having become available only after the current study had been initiated.
Finally, and perhaps most importantly, studies in rheumatoid arthritis have documented a reluctance among clinicians to adopt and apply clinical guidelines and recommendations in real-world practice, which may also apply to psoriatic arthritis, according to the researchers.
Since the time this study was conducted, newer agents for the treatment of psoriatic arthritis have been approved such as ustekinumab (Stelara) and secukinumab (Cosentyx). “With the increasing availability of novel drugs to treat psoriatic arthritis and the ongoing efforts on a consensus for treatment target, better understanding as to why residual disease activity does not lead to treatment adjustment” will be an important goal for optimizing outcomes in psoriatic arthritis, van Mens and colleagues concluded.
A limitation of the study was its cross-sectional design.
The study was supported by an unrestricted grant from UCB.
The authors reported financial relationships with UCB, Takeda, Tillotts, Merck Sharp & Dohme, Pfizer, AbbVie, Novartis, Janssen, Boehringer Ingelheim, Eli Lilly, Glenmark, Roche, and Celgene.
F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner