Drawing up evidenced-based recommendations or guidelines for psoriatic arthritis (PsA) is difficult due to the heterogeneous nature of the disease state and the many drug treatments available.
A new and universally recommended strategy in the management of PsA is the treat-to-target (T2T) approach, with the goal being remission or low-disease activity.
Shared decision-making is an important aspect of PsA therapy.
Treatment recommendations, or clinical practice guidelines, offer physicians the best evidence on which to base their clinical decisions, so that they can achieve optimal outcomes for their patients. But developing guidelines for psoriatic arthritis (PsA) has been difficult due to the heterogeneous nature of the disease and the introduction of several first-in-class therapies during the past decade.
With an expanding number of biologic therapies now available, the treatment landscape has become more complex, and clinicians look for guidance in selecting the right treatments. A treat-to-target (T2T) approach is recommended as an effective strategy for PsA.Read Next: Biologics can be scary for patients: Addressing your patient’s fears
The T2T approach is a concept that expanded from the realms of diabetes and heart disease to rheumatoid arthritis and other inflammatory diseases. Clinical trial evidence has shown that tight control with T2T can help patients with PsA as well.
The goal of T2T is to achieve remission or low-disease activity (ie, few signs of disease), by adjusting therapy accordingly.
With T2T, monitoring can be monthly or less frequently (every 3 or 6 months). At each visit, the patient is evaluated to see whether they have achieved their goal. If not, there are several options: Increase the medication dose, add a new drug, or switch drug classes. The process proceeds in a stepwise fashion, with increasingly aggressive therapies utilized until remission or low-disease activity is attained.
The patient evaluation for PsA needs to be comprehensive, because PsA has at least five distinct domains: joints, spine, skin/nail disease, dactylitis (a sausage-like swelling of the fingers/toes), and enthesitis (inflammation located where tendons and ligaments attach to bone).
All domains must be taken into account, although most patients don’t have symptoms in every domain. Little correlation exists between improvement in one domain of PsA and others.
PsA guidelines recommend T2T
The Arthritis Foundation acknowledges that T2T has not been the standard of care in PsA, as it is in RA, but guidelines from the American College of Rheumatology now recommend T2T for psoriatic arthritis, too.
Several organizations have published guidelines for PsA. In addition to the American College of Rheumatology (ACR)/National Psoriasis Foundation (NPF), these include the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and the European Alliance of Associations for Rheumatology (EULAR).
All three organizations recommend a T2T approach.
"Psoriatic arthritis can be more complicated than RA. "
— Arthritis Foundation
A major treatment difference
In a review article published in Rheumatology, North American researchers compared and contrasted guidance from these organizations.
According to the authors, although the guidance from the three organizations differs in terms of drug classification, drugs included at the time of publication, and terminology used, the treatment recommendations themselves are fairly uniform, with one exception: use of a TNF inhibitor (TNFi). Unlike GRAPPA and EULAR, the ACR/NPF recommends selecting a TNFi when actively treating treatment-naïve PsA patients.
In part, here’s what the ACR/NPF recommendation reads. Note that this is a conditional recommendation based on low- or very-low-quality evidence.
“In treatment-naive patients with active PsA, a TNFi biologic agent is recommended over an OSM [oral small molecule] as a first-line option. OSMs may be used instead of a TNFi biologic in patients without severe PsA and without severe psoriasis…, those who prefer an oral drug instead of parenteral therapy, or those with contraindications to TNFi treatment, including congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease.”
For a T2T approach to work, the Arthritis Foundation advises that patient preferences be discussed and considered, as part of shared decision-making. During patient discussions, the patient’s preference for an oral vs injectable drug should be assessed, as well as any contraindications to a TNFi.
Weighing the guidelines
When determining which treatment approach is best per guidelines and recommendations, there may be no one right choice, say the experts.
According to the Rheumatology authors, “There is no one best guideline recommended for all clinicians …. ” They explain that GRAPPA was designed for international application and has more information on skin and nail disease management, and that US and European rheumatologists may benefit from consulting the ACR/NPF and EULAR guidelines, respectively, which take into account local health economies.
What this means for you
A new and universal recommendation in the management of PsA is T2T. The goal of T2T is remission or low-disease activity. This goal should be evaluated at every visit, with medication regimens changed or adjusted as needed. When treating patients with PsA, shared decision-making is crucial, with patient preferences considered.
This article is part of Room for Better Rheum Care, where physicians and patients share the latest research, tips, and strategies for raising treatment expectations and delivering improved care in RA, PsA, and nr-AxSpA.