Psoriatic disease ‘decision tree’ needed to match treatment choices with target domains
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SAN DIEGO — The varying domains of psoriatic disease create challenges in defining treatment algorithms, according to a speaker at the 2023 Congress of Clinical Rheumatology West.
“We have this huge heterogeneity of psoriatic disease,” Frank Behrens, MD, head of the Inflammation Clinic at the University Hospital, and a deputy director of the Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP) at the Goethe-University Frankfurt, told attendees.
It is important to consider that experts in the field have moved away from the terms “psoriatic arthritis” and “psoriasis” in favor of the term “psoriatic disease” that encompasses the full spectrum of manifestations. “It is really rare to have a patient with psoriatic arthritis but no skin disease,” he said.
The other issue is if, or when, patients transition from an initial psoriasis rash to PsA, with all of its attendant comorbidities. “It is not like on Friday, they have psoriasis and on Monday, they have PsA,” Behrens said.
But experts continue to investigate the transition to more severe psoriatic disease for one important reason, according to Behrens. “The earlier we treat, the better the response,” he said.
But even this comes with complications. “Be careful of treating too early, because subclinical inflammation may not predict PsA,” Behrens said. “This is under investigation right now.”
Rheumatologists are encouraged to track manifestations, such as vascularization and nail involvement, to determine who may progress to more serious disease. “Nail psoriasis is really important in terms of predicting PsA,” Behrens said.
Once it has been established that the patient is moving to more severe psoriatic disease, treatment goals must be defined. Behrens highlighted the move toward treat-to-target paradigms across the rheumatology spectrum. “But to hit the correct target is a challenge,” he said.
A good place to start would be to lower inflammation as much as possible. “If you can control the inflammation, you lower the risk for other manifestations,” Behrens said.
Behrens is encouraged by an increasing therapeutic armamentarium to hit those treatment targets. “We have so many new therapeutic options available right now,” he said.
However, while organizations like American College of Rheumatology or the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) have published guidelines for treatment, Behrens acknowledged that they are often “non-specific” when it comes to selecting a therapy or class as a patient’s disease progresses. “There is no clear hierarchic order,” he said of the GRAPPA document.
Behrens offered some pearls for how to manage patients who are not responding to first-line therapy with methotrexate or leflunomide.
One consideration is adding a biologic to MTX. Some data show that the addition of a biologic to MTX “is unlikely to improve outcomes,” according to Behrens. “But it may have utility with TNF inhibitors,” he said. “There is always a ‘but’; it’s a nightmare.”
For clinicians to truly understand which medications to choose for which patients at which time, head-to-head trials, rather than placebo-controlled trials, are essential. However, data comparing mainstays, like adalimumab (Humira, Abbvie), with novel interleukinIL-17 inhibitors, like ixekizumab (Taltz, Eli Lilly & Co.) and secukinumab (Cosentyx, Novartis), are sparse. “We have a lot of meta-analyses of placebo trials, but we do not have direct comparisons,” he said.
That said, some signals are emerging with regard to which classes may have utility in which patient groups. “If it is pure arthritis, there may be no difference between classes,” Behrens said. “If it is enthesitis or uveitis, there may be some evidence that IL-17 and IL-23 inhibition may be more effective.”
Another suggestion is that abatacept (Orencia, Bristol Myers Squibb) can be effective in patients with more arthritic psoriatic disease. “Those patients who look most like RA, that is when abatacept is working,” Behrens said.
Guselkumab (Tremfya, Janssen) may have utility for skin disease. “IgA is now a very important aspect of global assessment," Behrens added.
Looking to the future, Behrens called on the research and clinical communities to develop a “decision tree” for patients with psoriatic disease. “This is what we have to develop in rheumatology,” he said. “For different parts of the tree — if the patient has IBD or enthesitis or uveitis — then you come up with treatment choices.”
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Behrens F. How Does the Efficacy of Targeted & Non-Targeted Molecules Vary in Specific Psoriatic Arthritis Subsets? Presented at The Congress of Clinical Rheumatology West; Sept. 7-10, 2023. (hybrid meeting).
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