Management of Axial Disease in Patients With Psoriatic Arthritis: An Updated Literature Review Informing the 2021 GRAPPA Treatment Recommendations

A strategy towards disentangling treatment refractory from misdiagnosed axial Spondyloarthritis

Axial spondyloarthritis (axSpA) encompasses radiographic axial SpA (r-axSpA), formally designated as ankylosing spondylitis (AS) and non-radiographic axial SpA (nr-axSpA). The advent of MRI permitted the description of the "pre-radiographic" (nr-AxSpA) stage characterized by bone marrow oedema lesions, histologically an osteitis, not yet visible on X-rays. Most subjects with a diagnosis of nr-axSpA do not progress to r-axSpA and the risk of misdiagnosis of nr-axSpA is considerable because back pain related to malalignment, degenerative conditions or biomechanical stress including intense exercise may lead to positive MRI scans. Even when nr-axSpA or r-axSpA are accurately diagnosed only about 40-50% achieve the ASAS40 responses with licensed therapies. It is likely that spinal enthesitis/osteitis leading to structural damage and associated damage contributes to post inflammatory disc territory secondary pain responses. Things are complicated as the concept of refractory axSpA itself is not well defined since there is no gold standard test to capture the full burden of inflammatory disease and, in any event, MRI has not been systematically applied. Nevertheless, there is sufficient evidence to borrow from the refractory rheumatoid arthritis field to propose two types of refractory axial SpA- a persistent inflammatory refractory ax-SpA (PIRaxSpA) and non-inflammatory refractory ax-SpA (NIRaxSpA). Both axSpA refractoriness and misdiagnosis need careful considerations when evaluating treatment failure. The immunological basis for axSpA immunotherapeutics non-responses is still rudimentary beyond the knowledge of HLA-B27 positivity status, CRP elevation, and MRI bone oedema that represents osteitis being equated with responder status.

Management of psoriatic arthritis: a consensus opinion by expert rheumatologists

Background

Psoriatic arthritis (PsA) is a chronic inflammatory musculoskeletal disease involving several articular and extra-articular structures. Despite the important progresses recently made in all of the aspects of this disease, its management is still burdened by unresolved issues. The aim of this exercise was to provide a set of statements that may be helpful for the management of PsA.

Methods

A group of 38 Italian rheumatologists with recognized expertise in PsA selected and addressed the following four topics: "early PsA," "axial-PsA," "extra-articular manifestations and comorbidities," "therapeutic goals." Relevant articles from the literature (2016-2022) were selected by the experts based on a PubMed search. A number of statements for each topic were elaborated.

Results

Ninety-four articles were selected and evaluated, 68 out of the 1,114 yielded by the literature search and 26 added by the Authors. Each of the four topic was subdivided in themes as follows: transition from psoriasis to PsA, imaging vs. CASPAR criteria in early diagnosis, early treatment for "early PsA"; axial-PsA vs. axialspondyloarthritis, diagnosis, clinical evaluation, treatment, standard radiography vs. magnetic resonance imaging for "axial PsA"; influence of inflammatory bowel disease on the therapeutic choice, cardiovascular comorbidity, bone damage, risk of infection for "comorbidities and extra-articular manifestations"; target and tools, treat-to-target strategy, role of imaging for "therapeutic goals." The final document consisted of 49 statements.

Discussion

The final product of this exercise is a set of statements concerning the main issues of PsA management offering an expert opinion for some unmet needs of this complex disease.

Real-world effectiveness and persistence of secukinumab in the treatment of patients with psoriatic arthritis

Introduction

Psoriatic arthritis (PsA) is a complex and heterogeneous inflammatory disease. Secukinumab, a biologic disease-modifying antirheumatic drug (bDMARD), has extensive clinical evidence of efficacy and safety in the treatment of PsA but data in clinical practice are still limited. This study aims to provide real-world evidence on secukinumab use, effectiveness, and persistence in PsA.

Methods

A retrospective, multicenter study was conducted on patients diagnosed with PsA and treated with secukinumab up to June 2021 at 12 centers in the Valencian Community (Spain). Data on DAS28-CRP, DAPSA, Tender and Swollen Joint Counts (TJC, SJC), enthesitis, dactylitis, skin and nail involvement, pain, patient and physician global assessment (ptGA, phGA) using 100-mm visual analog scale (VAS), and persistence for up to 24 months were collected.

Results

A total of 178 patients were included (49% men; mean [standard deviation, SD] age: 51.4 [10.5] years; 39% obese). Secukinumab was used as a first-, second-, or ≥ third-line bDMARD in 37, 21, and 42% of patients, respectively. The percentage of patients achieving at least low disease activity (DAS28-CRP ≤ 3.2) increased from 25% at baseline to 66% at month 6 (M6) and was maintained (75%) up to M24. Mean (SD) DAS28-CRP baseline values (3.9 [1.2]) decreased to 2.9 (1.1) (p < 0.001) at M6 and remained low through M24 (2.6 [1.1]) (p < 0.001). Secukinumab also improved peripheral arthritis increasing the percentage of patients with TJC = 0 (20% baseline; 57% M24) and SJC = 0 (37% baseline; 80% M24). Treatment reduced the percentage of patients with enthesitis (25% baseline; 6% M24), dactylitis (20% baseline; 4% M24), and skin (70% baseline; 17% M24), and nail (32% baseline; 2% M24) involvement. Additionally, we observed improvements in the mean pain VAS (-26.4 mm M24), ptGA (-26.2 mm M24), and phGA (-24.8 mm M24). Secukinumab showed an overall 24-month persistence rate of 67% (95% confidence interval [CI]: 60-74%). Patients receiving first-line secukinumab showed the highest 24-month persistence rate (83, 95% CI: 73-92; p = 0.024).

Conclusion

Secukinumab showed long-term effectiveness across the six key PsA domains thus reducing disease activity and pain, which are major treatment goals. This was accompanied by high persistence rates, especially in bDMARD naive patients.

GRAPPA 2021 Treatment Recommendations for Psoriatic Arthritis

At the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) 2022 annual meeting, the recently published new GRAPPA recommendations were presented and their unique characteristics highlighted, including their truly international approach, the inclusion of patient views from the very beginning, the representation by both rheumatologists and dermatologists, consideration of the diverse domains of psoriatic arthritis, and the inclusion of comorbidities to inform possible adverse events and their potential influence on treatment choices.

Difficult to Treat and Refractory to Treatment in Psoriatic Arthritis

Psoriatic arthritis (PsA) is a complex and chronic inflammatory condition in which the achievement of the best possible disease control has been proposed as the treatment target, which includes the possibility of reaching remission in all disease domains. However, due to the complexity of this multidomain disease, some patients may still have high disease activity in one or more domain and a high burden of disease, potentially leading to various treatment changes and to difficulty with the overall management. In this paper, we overview the concept of patients with difficult-to-treat PsA and the concept of patients with refractory-to-treatment PsA by providing a distinction between these two concepts and the possible implication for the management of patients with PsA.