Deeper disease insight signals 'exciting time' for PsA drug pipeline
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Patients with psoriatic arthritis have much to be hopeful about, with understanding of the disease increasing and an expanded range of treatment options available, according to a presenter at the 2020 Rheumatology Nurses Society Annual Conference.
Despite these advances, Christopher Ritchlin, MD, MPH, chief of the allergy, immunology and rheumatology division at the University of Rochester Medical Center, suggested in his presentation that there is considerable work to be done. One key concern is that many treatment approaches are effective in the skin manifestations of psoriasis but are less effective in targeting joints.
“There are 12 agents currently approved for the treatment of PsA, including adjunct therapies, and new therapies in development,” he said. “However, we have all of these options, but do these options really allow us to improve the joint impact of PsA? The answer is: not really.”
One major issue faced by patients with PsA is that they have a significant number of comorbidities, including decreased functional ability, reduced quality of life and obesity. “We must take all of this into account when crafting a treatment regimen,” Ritchlin said.
Another issue is what Ritchlin described as the “pathologic complexity” of this disease. He painted a picture of altered cellular populations, enthesitis in the joints, inflammatory pathways driven by interleukin (IL)-17, IL-23, tumor necrosis factor (TNF) and the Wnt signaling pathway. “It is a complex task” to account for all these factors when treating a patient, according to Ritchlin. “But I think we are up to it. We just have to think of a variety of strategies.”
One way to manage this complexity is to comprehensively evaluate patients. “We need to look at the presence or absence of peripheral arthritis, skin and nail disease, dactylitis and enthesitis,” Ritchlin said.
Another consideration is to think beyond pharmacotherapy. Ritchlin suggested that lifestyle modifications such as diet and exercise can reduce obesity and, thereby, improve parameters of inflammation.
An important part of that comprehensive evaluation is to determine sites of enthesitis in every patient. “This needs to be addressed at the initial visit and subsequent visits,” Ritchlin said. “There is a connection between enthesitis and other disease domains like skin and nail involvement and dactylitis. It is important to understand how many different structures can be involved in entheseal disease.”
If there is an area that needs to be understood more completely, it pertains to which patients are likely to transition from psoriasis to PsA. Data indicate that around 30% of patients will make this transition. Ritchlin said that the research community is pursuing a central question on this topic: “Can we identify those patients before they develop arthritis and treat them aggressively to stop this transition or delay onset?”
Regardless of whether a patient has psoriasis, PsA, or is transitioning from one to the other, Ritchlin noted that treatment paradigms call for a team approach. A cardiologist may be involved, along with a hepatologist to deal with fatty liver disease, primary care to handle general complaints and a behavioral therapist to deal with the depression and anxiety that often accompany the psoriatic diseases.
The good news in all of this, of course, is the ever-increasing treatment armamentarium. While methotrexate continues to be a mainstay of PsA treatment, use and approval of IL-17, IL-23 and TNF inhibitors are on the rise. “This is a very exciting area and pipeline space,” Ritchlin said. “It is a very exciting time for our patients because we have such a high number of treatment options.” —by Rob Volansky
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Ritchlin C. The Latest Treatments, Research, and Guidelines for Psoriatic Arthritis. Presented at: Rheumatology Nurses Society annual conference; August 5-8, 2020 (virtual meeting).
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