Now that psoriatic arthritis (PsA) is viewed as its own disease entity and no longer as a relative of rheumatoid arthritis, trends in PsA care have started to change.
Methotrexate (MTX) has become a first-line treatment for PsA despite a lack of evidence about its benefits, but advances for this common inflammatory arthropathy, such as new disease modifying antirheumatic agents (DMARDs), will be the focus of the state-of-the-art lecture Psoriatic Arthritis: Therapeutic Challenges at 1:00 pm Tuesday in Hall E.
“It is quite an exciting time for psoriatic arthritis because we are getting new drugs that are specific for this disease,” said Laura C. Coates, MBChB, PhD, National Institute for Health Research Clinical Lecturer in Rheumatology at the University of Leeds, United Kingdom. Dr. Coates will discuss efficacy data on new treatments, how patients should be selected for DMARD therapy, and monitoring clinical outcomes.
“A lot of newer drugs focus on the IL-17 pathway, which is a different part of the immune system (than what previous drugs targeted) and which seems to be particularly important for psoriatic arthritis, psoriasis, and spondylitis arthritis,” Dr. Coates said.
Dr. Coates will discuss the efficacy of secukinumab and ixekizumab, biologic DMARDs (bDMARDs) that inhibit IL-17 and that were recently or will soon be approved, respectively. She will also talk about IL-23 inhibitors, which is another class of bDMARD that targets the IL-17 pathway and are in early clinical testing; a dual inhibitor of IL-17 and TNF, which is the first example of this type of drug and will be presented in an abstract at the meeting; and JAK inhibitors, which are oral bMARDs that act on a different cytokine pathway than IL-17 and were originally developed for RA and are in clinical testing for PsA.
There are fewer new data on the synthetic DMARDs (sDMARDs) and increasing uncertainty among rheumatologists about whether to treat PsA patients with MTX, Dr. Coates said. She will present analysis of a recent randomized placebo-controlled trial of MTX suggesting that the drug could provide benefits for certain subsets of psoriatic arthritis patients.
“I think that methotrexate works better for polyarthritis and probably for small joint arthritis rather than larger joints, but that is more experience-based than trial-based,” she said.
Although there is no research-based evidence to guide physicians on whether a patient should receive an sDMARD or bDMARD, the decision usually comes down to disease severity and what healthcare systems and insurance providers cover, Dr. Coates said. In the United States and Europe, most providers require patients to fail to respond to at least one sDMARD before agreeing to cover a bDMARD.
There is currently a shift toward a treat-to-target approach in managing psoriatic arthritis, meaning that if a patient does not meet a predetermined clinical outcome with one treatment approach, the rheumatologist changes the treatment, such as prescribing a higher dose (in the case of sDMARD), a combination of sDMARDs, or switching the patient to a bDMARD.
“Treat-to-target results in changing treatment quicker if it is not working and aiming for a very high target of patients doing really well,” Dr. Coates said.
In her lecture, Dr. Coates will discuss the first randomized trial called TICOPA, which she and her colleagues conducted of a treat-to-target (TTT) approach. In response to its findings, the European League Against Rheumatism (EULAR) revised its PsA management recommendations to advise TTT.
One of the questions surrounding TTT is which tool should be used to assess clinical outcomes. In TICOPA, Dr. Coates and her colleagues used minimal disease activity, which included measurements of joint and skin disease and patient-reported outcomes that were taken at every visit. Dr. Coates will discuss this tool as well as key clinical outcome measures in PsA as recently updated by the GRAPPA/OMERACT group following work with both researchers and patients on key clinical outcomes.
CLINICAL PRACTICE TRACK
Psoriatic Arthritis: Therapeutic Challenges
1:00 – 2:00 pm Tuesday • Hall E