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

OBJECTIVE

We aimed to compile evidence for the efficacy and safety of therapeutic options for the peripheral arthritis domain of psoriatic arthritis (PsA) for the revised 2021 Group in Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) treatment recommendations.

METHODS

A working group consisting of clinicians and patient research partners was convened. We reviewed the evidence from new randomized controlled trials (RCTs) for PsA treatment from February 19, 2013, to August 28, 2020. We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE)-informed approach to derive evidence for the classes of therapeutic options for 3 patient groups: (1) naïve to treatment, (2) inadequate response to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), and (3) inadequate response to biologic DMARDs (bDMARDs). Recommendations were derived through consensus meetings.

RESULTS

The evidence review included 69 RCTs. We derived GRADE evidence for each class of therapeutic options and achieved consensus for the recommendations. For patients naïve to treatment, the working group strongly recommends csDMARDs (methotrexate, sulfasalazine, leflunomide) and phosphodiesterase 4 inhibitors, and emphasizes regular assessment and early escalation to achieve treatment target. bDMARDs (tumor necrosis factor inhibitors [TNFi], interleukin 17 inhibitors [IL-17i], IL-12/23i, IL-23i) and Janus kinase inhibitors (JAKi) are also strongly recommended. For patients with inadequate response to csDMARDs, we strongly recommend TNFi, IL-17i, IL-12/23i, IL-23i, and JAKi. For those who had prior experience with bDMARDs, we strongly recommend a second TNFi, IL-17i, IL-23i, and JAKi. The evidence supporting nonpharmacological interventions was very low. An expert panel conditionally recommends adequate physical activity, smoking cessation, and diet to control weight gain.

CONCLUSION

Evidence supporting optimal therapy for the peripheral arthritis domain of PsA was compiled for the revised 2021 GRAPPA treatment recommendations.

3D Visualization of Human Blood Vascular Networks Using Single-Domain Antibodies Directed against Endothelial Cell-Selective Adhesion Molecule (ESAM)

High-quality three-dimensional (3D) microscopy allows detailed, unrestricted and non-destructive imaging of entire volumetric tissue specimens and can therefore increase the diagnostic accuracy of histopathological tissue analysis. However, commonly used IgG antibodies are oftentimes not applicable to 3D imaging, due to their relatively large size and consequently inadequate tissue penetration and penetration speed. The lack of suitable reagents for 3D histopathology can be overcome by an emerging class of single-domain antibodies, referred to as nanobodies (Nbs), which can facilitate rapid and superior 2D and 3D histological stainings. Here, we report the generation and experimental validation of Nbs directed against the human endothelial cell-selective adhesion molecule (hESAM), which enables spatial visualization of blood vascular networks in whole-mount 3D imaging. After analysis of Nb binding properties and quality, selected Nb clones were validated in 2D and 3D imaging approaches, demonstrating comparable staining qualities to commercially available hESAM antibodies in 2D, as well as rapid and complete staining of entire specimens in 3D. We propose that the presented hESAM-Nbs can serve as novel blood vessel markers in academic research and can potentially improve 3D histopathological diagnostics of entire human tissue specimens, leading to improved treatment and superior patient outcomes.

AB0531 THERAPIES FOR PERIPHERAL JOINT INVOLVEMENT IN PSORIATIC ARTHRITIS: A SYSTEMATIC LITERATURE REVIEW

Background:

Much new information has been reported since the last evidence-based GRAPPA recommendations for the treatment of psoriasis and psoriatic arthritis (PsA).

Objectives:

We aimed to compile the evidence for the efficacy and safety of established and newly developed drugs targeting the peripheral arthritis domain in PsA so as to provide information for the revised GRAPPA treatment recommendations.

Methods:

A working group consisting of clinicians and patient research partners (PRPs) was convened. We performed an updated systematic literature review (SLR) of randomized controlled trials (RCTs) for the treatment of PsA, including peripheral arthritis, from the date of the last GRAPPA SLR, from February 19, 2013 to August 28, 2020. The working group reviewed the evidence supporting the efficacy on peripheral arthritis for each class of drug, according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, for three patients groups: 1) naïve to treatment; 2) refractory to conventional (-c)DMARDs; and 3) with prior biological (-b)DMARD experience. We also evaluated the evidence for non-pharmacological treatments. A set of important outcomes for the peripheral arthritis domain was assessed for each class of medication. The certainty of evidence supporting each class of drugs for each patient group was evaluated. Recommendations were derived through consensus meetings.

Results:

87 articles from 52 RCTs were included. For patients with mild disease who are naïve to treatment, the working group strongly recommends csDMARDs (methotrexate, sulfasalazine, leflunomide) and PDE4i, and weakly recommends them for severe disease, where TNFi are preferred over csDMARDs. Other bDMARDs (IL-17i, IL-12/23i, IL-23i) and JAKi are strongly recommended to treat peripheral arthritis for treatment naïve patients. For patients with inadequate response to csDMARDs, we strongly recommend TNFi, IL-17i, IL-12/23i, IL-23i and JAKi. For those who had prior experience with bDMARDs, we strongly recommend a second TNFi, IL-17i, IL-23i and JAKi. Certainty of evidence (GRADE) and recommendations for peripheral arthritis domain of PsA for different population groups are shown in Table 1. While the evidence supporting non-pharmacological treatments was low, we derived the recommendations from clinician/PRP expert opinion, included advocating an increase in physical activity, smoking cessation and a healthy diet to control weight gain.

Conclusion:

Evidence supporting drug treatment for the peripheral arthritis domain of PsA was compiled, providing required information for the revised GRAPPA treatment recommendations. Further work seeking agreement from a broader group of stakeholders is in progress.

Table 1.

Certainty of evidence (GRADE) and Recommendation for peripheral arthritis of PsA

Treatment naivecsDMARD inadequate responsebDMARD inadequate responseDrug classevidence (GRADE)Recom-mendationevidence (GRADE)Recom-mendationevidence (GRADE)Recom-mendationPDE-4iMod to highStrong for(mild/ mod disease)Conditional for(severe disease)Mod to HighStrong forbDMARD exp: ModbDMARD IR: Mod (NS)Conditional for (bDMARD exp)Conditional against (bDMARD IR)TNFiHighStrong forHighStrong forModStrong fora 2ndTNFiTNFiVs. MTXHighStrong for TNFi as 1st line for severe disease----IL-17iHighStrong forHighStrong forMod to highStrong forIL-12/23iMod to highStrong forMod to HighStrong forLowConditional forIL-23iHighStrong forHighStrong forModStrong forJAKiMod*Strong forHighStrong forMod to HighStrong forCTLA4iVery LowConditional for†LowConditional for†Mod (NS)Conditional for†Dual TNFi/ IL17iModerateNA¥ModNA¥NANA¥IL-6iVery LowConditional againstVery low to lowConditional againstNAConditional against

NS: not statistically significant; *included data from abstract; ¥ not making recommendation due to not approved and not available in market; †reserve for no alternatives. Mod: Moderate; exp: experienced; IR: inadequate response.

Acknowledgements:

We are grateful to the contribution of our patient research partner, Rodrigo Firmino.

Disclosure of Interests:

None declared.

Apolipoprotein A-I Limits the Negative Effect of Tumor Necrosis Factor on Lymphangiogenesis

OBJECTIVE

Lymphatic endothelial dysfunction underlies the pathogenesis of many chronic inflammatory disorders. The proinflammatory cytokine tumor necrosis factor (TNF) is known for its role in disrupting the function of the lymphatic vasculature. This study investigates the ability of apolipoprotein (apo) A-I, the principal apolipoprotein of high-density lipoproteins, to preserve the normal function of lymphatic endothelial cells treated with TNF.

APPROACH AND RESULTS

TNF decreased the ability of lymphatic endothelial cells to form tube-like structures. Preincubation of lymphatic endothelial cells with apoA-I attenuated the TNF-mediated inhibition of tube formation in a concentration-dependent manner. In addition, apoA-I reversed the TNF-mediated suppression of lymphatic endothelial cell migration and lymphatic outgrowth in thoracic duct rings. ApoA-I also abrogated the negative effect of TNF on lymphatic neovascularization in an ATP-binding cassette transporter A1-dependent manner. At the molecular level, this involved downregulation of TNF receptor-1 and the conservation of prospero-related homeobox gene-1 expression, a master regulator of lymphangiogenesis. ApoA-I also re-established the normal phenotype of the lymphatic network in the diaphragms of human TNF transgenic mice.

CONCLUSIONS

ApoA-I restores the neovascularization capacity of the lymphatic system during TNF-mediated inflammation. This study provides a proof-of-concept that high-density lipoprotein-based therapeutic strategies may attenuate chronic inflammation via its action on lymphatic vasculature.

Lymphatic vessels are essential for the removal of cholesterol from peripheral tissues by SR-BI-mediated transport of HDL

Removal of cholesterol from peripheral tissues to the bloodstream via reverse cholesterol transport (RCT) is a process of major biological importance. Here we demonstrate that lymphatic drainage is required for RCT. We have previously shown that hypercholesterolemia in mice is associated with impaired lymphatic drainage and increased lipid accumulation in peripheral tissues. We now show that restoration of lymphatic drainage in these mice significantly improves cholesterol clearance. Conversely, obstruction of lymphatic vessels in wild-type mice significantly impairs RCT. Finally, we demonstrate using silencing RNA interference, neutralizing antibody, and transgenic mice that removal of cholesterol by lymphatic vessels is dependent on the uptake and transcytosis of HDL by scavenger receptor class B type I expressed on lymphatic endothelium. Collectively, this study challenges the current view that lymphatic endothelium is a passive exchange barrier for cholesterol transport and provides further evidence for its interplay with lipid biology in health and disease.