Growing psoriatic arthritis armamentarium can target specific disease domains
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DESTIN, Fla. — An ever-increasing array of treatment options is allowing rheumatologists to target specific disease domains in their patients with psoriatic arthritis, according to a speaker at the Congress of Clinical Rheumatology East.
Although TNF inhibitors have been the “gold standard for a long time,” interleukin-12/23 and IL-17 inhibitors, along with cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) targeted therapies and janus kinase (JAK) inhibitors all offer various options, said Arthur Kavanaugh, MD, a rheumatologist and professor of medicine at the University of California, San Diego. For example, the introduction of IL-12/23 inhibition showed an improvement in skin domains compared with TNF inhibition, he added.
“After that, the IL-17 inhibitors actually work better than the IL-12/23 inhibitors in the skin,” Kavanaugh said.
Regarding the joints, Kavanaugh suggested that IL-12/23 inhibitors also have shown efficacy in these domains. In addition, although IL-17 inhibitors are generally known for inducing improvements in the skin, they may also have utility in the joints.
“They also do pretty well in patients with peripheral disease, he added.
For patients with ankylosing spondylitis as part of PsA, both IL-12/23 and IL-17 inhibitors are “inefficient,” according to Kavanaugh. Meanwhile, IL-17 inhibitors were a “big surprise” in PsA-associated bowel disease, he added.
“They were supposed to work, and they did not,” Kavanaugh said.
Regarding novel combination strategies, Kavanaugh noted that the addition of a TNF inhibitor to methotrexate may be more effective than simply increasing the methotrexate dose.
“There is a chance that the improvement across domains with elevated methotrexate is not as much as you would get with the addition of a TNF inhibitor,” he said.
Investigation of combination cytokine therapy with an IL-23 inhibitor plus a TNF inhibitor vs. either of those approaches alone is currently under way.
“There are very exciting results,” Kavanaugh said, noting that there may be a benefit in the combination without an increase in toxicity. “There is an ongoing study of this approach in PsA that is getting us toward the idea of using combination therapy in psoriatic arthritis.”
Ultimately, Kavanaugh encouraged clinicians to use shared decision-making as much as possible when treating PsA.
“What is the most important domain to the patient?” he said. “I want to pick something that covers that the most.”
However, despite an increasing number of therapeutic options, Kavanaugh cautioned that there are still more questions than answers in this disease.
“We know that 20% to 25% of patients with psoriasis develop psoriatic arthritis,” he said. “But we don’t know which ones.”
That said, researchers have attempted to answer an associated question.
“What if we treated psoriasis more aggressively, would that inhibit the development of PsA?” Kavanaugh asked. “The answer is: Absolutely, positively, we don’t know.”
It is also unknown whether aggressive treatment of psoriasis can ultimately prevent PsA, according to Kavanaugh.
“We also do not know why certain patients develop different disease domains,” he said.
Still, not all is uncertain. Kavanaugh highlighted peripheral arthritis, enthesitis, dactylitis, axial spondyloarthritis, nail disease, uveitis and inflammatory bowel disease as the key manifestations. In the absence of a clear understanding of how these domains develop, he believes it is possible for clinicians to use the “art” in addition to the “science” of medicine.
“You should ask your patient, ‘What involvement do you have, and what is most important to you?’ ” Kavanaugh said. “PsA treatment is all about the domains.”
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Kavanaugh A. Psoriatic arthritis: What’s new in 2022? Presented at: The Congress of Clinical Rheumatology East; May 12-15, 2022; Destin, Fla.
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