Sharing treatment target goals, 'mutual conversation' with patients key to PsA outcomes
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Clearly defining treatment targets and communicating those targets to patients is essential to optimizing outcomes in psoriatic arthritis, according to a presenter at the 2021 Congress of Clinical Rheumatology-West.
“There is a single objective for this talk,” Philip J. Mease, MD, of the Swedish Medical Center and the University of Washington, said in his presentation. “Those of you who are practitioners will come away being able to share a treatment target goal with your patients, and then strive together to reach that goal.”
Defining treatment targets begins with an understanding of all of the domains and parameters that may be relevant in PsA, according to Mease. These include musculoskeletal disease activity, skin disease activity, patient global assessment, pain, physical function, health-related quality of life (QOL), fatigue and systemic inflammation.
“Treatment targets should be individualized to the current manifestations of disease,” Mease said, and then compared PsA to an orchestra. “At different moments, different sections of the orchestra can be in action. It is important to take the time to identify that carefully.”
Mease believes in minimal disease activity as a key parameter for defining treatment targets or remission. “Clinical remission in active disease is defined as the absence of clinical and laboratory evidence of significant inflammatory disease activity,” he said.
Mease outlined the MDA assessment, which is defined as swollen and tender joint counts of 1 or less, Psoriasis Area and Severity Index (PASI) score of 1 or less or body surface area of 3% or less, patient pain visual analog score of 15 or lower, patient global disease activity score of 20 or lower, Health Assessment Questionnaire Disability Index (HAQ-DI) with an upper limit of 0.5 and tender entheseal points of 1 or less. “MDA would be my vote,” he said.
Clinical trials have consistently shown that MDA correlates with a number of PsA domains, ranging from radiographic progression to fatigue.
It is necessary to understand that communicating with patients is a necessary component to achieving treatment outcomes. “Sometimes we, in our mind, know what the treatment target is, but we do not always articulate that to the patient,” Mease said. “Then you realize that your treatment goals are different from theirs.”
For example, many rheumatologists are focused on preventing structural damage or quieting inflammation to reduce cardiovascular risk. However, Mease repeated a mantra voiced by so many other experts who treat autoimmune and rheumatic diseases, which is that fatigue is so important to patients. “It is important for you to listen,” he said. “Certain things are paramount to the patient that you might not have thought were so important.”
Mease suggested that listening can lead to the most important decisions a doctor and patient can make, which are those pertaining to therapeutic options. He said that understanding where patients stand on the various disease domains can dictate whether to remain on course, tweak current doses or change treatments altogether. “It has to be that mutual conversation,” he said.
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Mease PJ. Treating to Target in Psoriatic Arthritis: Minimal Disease Activity. Presented at: Congress of Clinical Rheumatology-West annual symposium; September 18-21, 2021 (hybrid meeting).
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