Comparing methotrexate monotherapy with methotrexate plus leflunomide combination therapy in psoriatic arthritis: protocol of a randomized, placebo-controlled, double-blind clinical trial (COMPLETE-PsA)

Psoriatic arthritis: A comprehensive review for the dermatologist-Part II: Screening and management

Psoriatic arthritis (PsA) is a common comorbidity of psoriasis occurring in up to one-third of patients. Dermatologists hold an essential role in screening patients with psoriasis for PsA, since as many as 85% of patients develop psoriasis before PsA. Early detection and treatment of PsA are important for both short- and long-term patient outcomes and quality of life. Many factors must be weighed when selecting the appropriate therapy for PsA. One must consider the 'domains of disease' that are manifested, the disease severity, patient comorbidities, patient preferences (routes of dosing or frequency, as examples) as well as factors often outside of patient-physician control, such as access to medications based on insurance coverage and formularies. As many patients will have involvement of multiple domains of psoriatic disease, selecting the therapy that best captures the patient's disease is required. In this review, we will address PsA screening, diagnosis, therapeutic approach to psoriatic disease, comorbidity considerations, and comanagement.

IL-23 inhibition for chronic inflammatory disease

Biological monoclonal antibody drugs inhibit overactive cytokine signalling that drives chronic inflammatory disease in different organ systems. In the last 10 years, interleukin (IL)-23 inhibitors have attained an important position in the treatment of psoriatic skin and joint disease as well as inflammatory bowel diseases. Addressing an upstream pathological mechanism shared between these disorders, this drug class has high efficacy rates and a durable response that extends dosing intervals up to 3 months. Pooled clinical trial data show objective disease improvement for more than 70% of patients with psoriasis and up to 50% of patients with inflammatory bowel disease. The first antibody inhibitor for IL-23A targeted a p40 subunit shared with IL-12. Subsequently, even greater improvement was established for inhibitors of the p19 protein unique to IL-23A. IL-23 p19 inhibitors elicit clinical response in both bio-naive and bio-exposed patients and show superiority to tumour necrosis factor α inhibitors in plaque psoriasis. Reported differences in efficacy between p19 inhibitors suggest that individual drug action might be modulated by antibody affinity. Although long-term safety data are accumulating, rates of serious adverse events and infections for interleukin (IL)-23 inhibitors are similar to the rates for placebo across approved indications.

Consensus statements for pharmacological management, monitoring of therapies, and comorbidity management of psoriatic arthritis in the United Arab Emirates

OBJECTIVE

Psoriatic arthritis (PsA), a chronic inflammatory disease characterized by heterogeneous clinical manifestations, substantially impacts the quality of life of affected individuals. This article aims at developing consensus recommendations for the management of PsA and associated comorbidities and screening and monitoring requirements of PsA therapies in the United Arab Emirates (UAE) population.

METHODS

An extensive review of present international and regional guidelines and publications on the pharmacological management, monitoring of therapies in the context of PsA was performed. Key findings from guidelines and literature were reviewed by a panel of experts from the UAE at several meetings to align with current clinical practices. Consensus statements were formulated based on collective agreement of the experts and members of Emirates Society for Rheumatology.

RESULTS

The consensus recommendations were developed to aid practitioners in clinical decision-making with respect to dosage recommendations for pharmacological therapies for PsA, including conventional drugs, non-biologic, and biologic therapies. Consensus recommendations for therapeutic options for the treatment of PsA domains, including peripheral arthritis, axial disease, enthesitis, dactylitis, psoriasis, and nail disease, were developed. The panel emphasized the importance of monitoring PsA therapies and arrived at a consensus on monitoring requirements for PsA therapies. The expert panel proposed recommendations for the management of common comorbidities associated with PsA.

CONCLUSION

These consensus recommendations can guide physicians and healthcare professionals in the UAE in making proper treatment decisions, as well as efficiently managing comorbidities and monitoring therapies in patients with PsA.

Conventional Synthetic Disease-Modifying Anti-rheumatic Drugs for Psoriatic Arthritis: Findings and Implications From a Patient Centered Longitudinal Study in Brazil

Background: Conventional synthetic disease-modifying antirheumatic drugs are the first-line treatment to inhibit the progression of psoriatic arthritis. Despite their widespread clinical use, few studies have been conducted to compare these drugs for psoriatic arthritis. Methods: a longitudinal study was carried out based on a centered patient national database in Brazil. Market share of drugs, medication persistence, drug costs, and cost per response were evaluated. Results: a total of 1,999 individuals with psoriatic arthritis were included. Methotrexate was the most used drug (44.4%), followed by leflunomide (40.6%), ciclosporin (8.2%), and sulfasalazine (6.8%). Methotrexate and leflunomide had a greater market share than ciclosporin and sulfasalazine over years. Medication persistence was higher for leflunomide (58.9 and 28.2%), followed by methotrexate (51.6 and 25.4%) at six and 12 months, respectively. Leflunomide was deemed the most expensive drug, with an average annual cost of $317.25, followed by sulfasalazine ($106.47), ciclosporin ($97.64), and methotrexate ($40.23). Methotrexate was the drug being the lowest cost per response. Conclusion: Methotrexate had the best cost per response ratio, owing to its lower cost and a slightly lower proportion of persistent patients when compared to leflunomide. Leflunomide had a slightly higher medication persistence than methotrexate, but it was the most expensive drug.

The IL-17/IL-23 Axis and Its Genetic Contribution to Psoriatic Arthritis

Psoriatic arthritis (PsA) is a chronic inflammatory disease belonging to the family of spondyloarthropathies (SpA). PsA commonly aggravates psoriasis of the skin and frequently manifests as an oligoarthritis with axial skeletal involvement and extraarticular manifestations including dactylitis, enthesitis, and uveitis. The weight of genetic predisposition to psoriasis and PsA is illustrated by the concordance rates in monozygotic twins which clearly demonstrate that genomics is insufficient to induce the clinical phenotype. The association of PsA with several single nucleotide polymorphisms (SNPs) at the IL23R locus and the involvement of Th17 cells in the immunopathogenesis of PsA clearly put the IL-23/IL-17 axis in the spotlight. The IL-23 and IL-17 cytokines have a pivotal role in the chronic inflammation of the synovium in PsA and are also prominent in the skin lesions of those with PsA. In this review, we focus on the genetic association of the IL-23/IL-17 axis with PsA and the contribution of these master cytokines in the pathophysiology of the disease, highlighting the main cell types incriminated in PsA and their specific role in the peripheral blood, lesional skin and joints of patients. We then provide an overview of the approved biologic drugs targeting the IL-23/IL-17 axis and discuss the advantages of genetic stratification to enhance personalized therapies in PsA.