Combination therapy, personalized medicine on the horizon in psoriatic arthritis
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There is much to look forward to in the management of psoriatic arthritis, according to a presenter at the 2020 Congress of Clinical Rheumatology-East.
In a live virtual session, Arthur Kavanaugh, MD, professor of medicine at the University of California, San Diego, provided an update on recent progress in psoriatic arthritis, including therapeutic targets and predictions for the future care of these patients.
“As you look through all the studies of psoriatic arthritis, of therapeutic agents, and look at the duration of skin psoriasis and duration of PsA. Often patients have had psoriasis for about 10 years or more and then develop PsA. At some point in the future, we know there’s an answer to that,” Kavanaugh said. “The rheumatology aspect of care of PsA may be something they no longer talk about in the future because if it’s been figured out who will develop PsA, maybe treatment of those patients early may ultimately prevent them from getting PsA. So, some exciting work may be in the foreseeable future, certainly 10 or 20 years down the road.”
According to Kavanaugh, about 25% of patients with psoriasis will develop PsA, and although sometimes considered to be rheumatoid arthritis with skin psoriasis, the clinical features, joint involvement, immunopathogenic and genetic features differentiate PsA from RA.
Recognizing extra-articular features, or PsA domains, such as enthesitis, dactylitis, skin and nail psoriasis, axial arthritis, peripheral arthritis, iritis and IBD, is crucial to patient care, as the extent of activity across these domains ultimately affects treatment choices, Kavanaugh said.
“In the care of patients with PsA, we want all of the different domains to get better,” he said. “The goal we have when treating patients to get maximum improvements across all domains is very important because what we want to do is make quality of life as good as it can possibly be.”
In terms of treatment options, there are many — from adjunctive therapies (NSAIDs), to DMARDs, biologics/biosimilars, JAK inhibitors, PDE4 inhibitors and experimental options — with more on the way. TNF inhibitors remain the go-to biologic option, according to Kavanaugh, and the field awaits a compound that’s “convincingly better across domains of the disease than TNF inhibitors.”
Similarly, answers to questions regarding TNF discontinuation and the effects of treating PsA early are anticipated.
Newer mechanisms include the IL-12/IL-23 inhibitor ustekinumab (Stelara, Janssen), a “pivotal” drug that has signaled to dermatologists that there may be an agent superior to TNF inhibitors for skin psoriasis, according to Kavanaugh. There is also great interest in IL-17 inhibition, with data for various targets and agents, such as ixekizumab (Taltz, Eli Lilly & Co.), secukinumab (Cosentyx, Novartis), brodalumab (Siliq, Valeant Luxembourg) and bimekizumab (UCB).
One of the most exciting things the field has seen, Kavanaugh said, are head-to-head trials, citing data from EXCEED (secukinumab vs. adalimumab) and SPIRIT (ixekizumab vs. adalimumab [Humira, AbbVie]). Trials like these, coupled with data from the Corrona registry, add interest to questions regarding combination therapy for patients with PsA.
“In PsA, I think we’ll jump ahead of RA and talk about combination therapy,” Kavanaugh said, specifically referencing data on the increased use of apremilast (Otezla, Amgen) plus biologic therapy from the Corrona registry. “There is natural appeal because of the safety profile of apremilast. This shows, we as a community, are open to combinations of different therapies; I think we’ll see a lot more like this in the future.”
Kavanaugh was also optimistic about the potential for personalized medicine for patients with PsA, although the path has been slow going, the filed is getting there.
“Finally, something that sounds like pie in the sky, but we may see, if we treat psoriasis so effectively, might we prevent PsA? There are so many exciting things we may be able to see in the future,” he said.
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Kavanaugh A. Psoriatic Arthritis – 2020 Update. Presented at: Congress of Clinical Rheumatology-East annual symposium; September 10-13, 2020 (virtual meeting).
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