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DAPSA-based Remission Better Detects Patient-perceived Remission in PsA
Remission and low disease activity in psoriatic arthritis, as defined by the Disease Activity Index for Psoriatic Arthritis, better detected patients’ definition of remission and low disease activity compared to “very low disease activity” and “minimal disease activity” measures, according to data published in the Annals of the Rheumatic Diseases.
“As remission is the proposed objective of treatment in psoriatic arthritis, it is very important to gain more knowledge on what this remission means for patients,” Laure Gossec, MD, PhD, of Sorbonne University in Paris, and colleagues wrote. “Several composite disease activity measures have been developed, and the currently discussed treatment target definitions for [remission/low disease activity] are [very low disease activity/[minimal disease activity] and DAPSA (Disease Activity index for Psoriatic Arthritis) cut-offs of 4/ 14 (or clinical DAPSA, cDAPSA). These definitions each have strengths and weaknesses which hamper achieving consensus on one definition.”
To compare various definitions of remission and low disease activity among patients with PsA, based on patients’ and physicians’ perspectives, Gossec and colleagues established the Remission/Flare in PsA (ReFlap) study, a prospective, longitudinal observational trial of adults with PsA for at least 2 years. A total of 466 participants were recruited at 21 centers in 14 countries in Asia, Europe, North America and South America. Of those, 410 were included in the final analysis after 56 were determined to have missing data.
The researchers defined remission as very low disease activity, a DAPSA of 4 or less, and physician-perceived and patient-perceived remission. Low disease activity was defined as as minimal disease activity, a DAPSA score of less than 14, and the perception of the physician and patient. Frequencies of these definitions, their agreement — based on prevalence-adjusted kappa — and sensitivity and specificity versus patient-defined status were evaluated cross-sectionally.
According to the researchers, remission or low disease activity was frequently attained among the 410 patients. For remission, 12.4% achieved very low disease activity while 36.1% demonstrated physician-perceived remission. For low disease activity, 25.4% saw minimal disease activity while 43.9% achieved patient-perceived low disease activity. Patient-perceived remission or low disease activity occurred in 65.4% of cases.
Agreement between patient-perceived remission or low disease activity and composite scores was moderate to good, with a kappa range of 0.12 to 0.65, the researchers wrote. DAPSA-defined remission or low disease activity had a sensitivity of 73.1%, compared with 51.5% for very low disease activity and minimal disease activity. Specificity measures were 76.8% for DAPSA-defined remission or low disease activity and 88% for very low disease activity and minimal disease activity. Physician-perceived remission and low disease activity, using a single question, was achieved in 67.6% of cases, but performed poorly against the other definitions.
“We found that patients self-estimated themselves in remission as often as physicians found them to be in remission using composite scores, however, the agreement between the patient assessment and the physician scores was not perfect,” Gossec told Healio Rheumatology. “Some patients find they are doing well when physicians find their disease to be active, and others will estimate they are not doing well when their disease is in inflammatory remission. This warrants further studies of treatment objectives, especially in the context of shared decision making.” – by Jason Laday
Disclosure: Gossec reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Gorlier and colleagues did an excellent job of comparing the different definitions of remission and low disease activity in psoriatic arthritis patients, based on both patient and physician perspectives. As a large international study of non-randomized PsA patients seen in their rheumatology clinic settings for their standard of care treatments, the ReFlaP (Remission/Flare in PsA) study was especially important because it explored the patient’s perspective and definition of remission (REM) and low disease activity (LDA), which is essential when you want to define a specific target for REM/LDA.
This study found that patient-perceived REM/LDA occurred frequently (65%) and was similar in terms of prevalence to physician-perceived REM/LDA (68%). There are various instruments to measure REM/LDA and although this study demonstrated that no one measurement could detect all, which can lead to perceived REM/LDA, the Disease Activity index for Psoriatic Arthritis (DAPSA) fared the best.
A notable weakness of this study was that it followed patients in a rheumatology clinic where the majority were on biologics and had limited skin involvement. More work needs to be done — for instance, a study comparing PsA patients seen in a combination rheumatology/dermatology clinic as well as the perceived REM and LDA in patients with both skin and joint manifestations.
Perspective
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Assessment of disease activity plays a central role in the management of all inflammatory arthridities and is the key to appropriate therapeutic decisions. Over the last two decades, it has become clear that treating to target — or at least some form of measurement in the process of clinical decision-making — is essential and superior to the alternative of “gestalt” or “How you doing?”
There remains much controversy in this area however, with a great push toward patient-reported outcomes (PROs), such as the RAPID3, and alternatively toward much more physician- and lab-centric measures, such as the DAS28, with benefits and disadvantages on both ends of the spectrum. In psoriatic arthritis, this has been further magnified by the diversity of manifestations and domains involved in this multicentric disorder.
Gorlier and colleagues have brought a great deal to this discussion in the current multinational study of 410 standard-of-care patients with PsA. The researchers compare two composite scores that can be used by physicians to treat to the target of remission or low disease activity and compare them for the first time to a patient-reported standard of self-assessment of these states.
Both Disease Activity index for Psoriatic Arthritis (DAPSA) and Very Low Disease Activity/Minimal Disease Activity (VLDA/MDA) were good tools for determining remission or low disease activity when correlated with patient perception of the same, with DAPSA showing a higher sensitivity but VLDA/MDA demonstrating higher specificity. Each has its limitations; DAPSA assesses only the joints and not other domains (such as skin or enthesitis) and MDA does not include dactylitis or spondylitis while including a health assessment questionnaire that may introduce factors other than pure disease activity.
Perhaps one of the most important findings, however, was overestimation of remission by physicians that did not correlate with patient-reported assessment or either the DAPSA or VLDA tools. This would suggest physician expectations of remission are too low with a likelihood of undertreatment. This both pushes our standard of care to one of maximum patient benefit and provides further understanding of the reasons for improved outcomes demonstrated with treat-to-target protocols such as TICOPA.