Better than ‘trial and error’: Treat-to-target beneficial in complex psoriatic arthritis
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SAN DIEGO — Domain-based or treat-to-target approaches can be effective in managing patients with complex psoriatic arthritis and avoiding “just trial and error,” according to a speaker at the Congress of Clinical Rheumatology West.
“There is a lot that’s happening in psoriatic arthritis,” M. Elaine Husni, MD, MPH, of the Cleveland Clinic, told attendees.
Husni noted that there are three recommendation documents to guide treatment decision-making: the American College of Rheumatology/National Psoriasis Foundation (ACR/NPF) joint guideline, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) guidelines and the EULAR guidelines.
Moreover, novel drug classes to treat the many domains of PsA — from mainstays like TNF inhibitors to interleukin-17 and IL-23 inhibitors — are moving through clinical trials to market, providing a host of options for rheumatologists to consider.
“We have all these emerging agents,” Husni said. “How do we put them all together in the office?”
Of particular concern are those domains, according to Husni. These include peripheral arthritis, axial disease, enthesitis, dactylitis and skin involvement. In addition, patients with PsA can demonstrate multiple clinical patterns, including distal, oligoarticular, polyarticular, primary axial and arthritis mutilans.
“We are asked to pick one DMARD treatment that is going to cover all these areas,” Husni said. “That is what makes this disease so difficult.”
Any given patient with PsA can demonstrate “intertwining” involvement of these domains and presentations.
“Also, they may demonstrate one or two domains at a time,” Husni said.
However, the challenges do not stop there, according to Husni.
“They can switch over time, as well,” she added.
Yet another issue is that although some patients can present with mild disease in both the skin and joints, many present with mild skin disease and severe joint involvement, or vice versa.
“This is when the art of medicine comes in,” Husni said.
The good news is that the aforementioned guideline documents can be of particular use.
The ACR/NPF document is framed in terms of clinical scenarios, according to Husni. “GRAPPA is more of a stepwise approach,” she said.
Meanwhile, EULAR offers more of a domain-based strategy.
“There are little nuances in the way they approach the disease,” Husni added.
Questions rheumatologists should consider as they consult these guidelines include when to switch drug classes if one is not working, when to go to a different mode of action and when to consider a biosimilar.
The overarching issue these documents aim to resolve is whether it is possible “to do better than just trial and error” in treating patients with PsA, according to Husni.
To that end, the evolution toward a treat-to-target approach can be beneficial.
“We see that a treat-to-target approach does help people with PsA,” she said.
That said, there is one stumbling block that continues to plague PsA management.
“We may always be at a trial-and-error period because we do not yet have biomarkers,” Husni said.
She noted that different microenvironments may be driving the different domains of the disease, but that the research community has yet to pinpoint which factors are driving joint involvement and which are driving skin and nail involvement.
“There are so many options out there,” Husni said. “Some are better in the skin and some are better in the joints. This is what makes PsA treatment challenging and fun.”
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Husni E. Presented at the Congress of Clinical Rheumatology West; Oct. 20-23, 2022. (hybrid meeting).
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