Trends in care for patients with psoriatic arthritis have begun to change, as the disease is now being viewed as separate from rheumatoid arthritis.
Methotrexate has become the first-line treatment for this disease, although these is a lack of evidence about its effects. Additional advances for psoriatic arthritis treatment were discussed at the Psoriatic Arthritis: Therapeutic Challenges
session at the American College of Rheumatology and Association of Rheumatology Health Professionals annual meeting.
“It is quite an exciting time for psoriatic arthritis because we are getting new drugs that are specific for this disease,” said Laura C. Coates, MBChB, PhD, National Institute for Health Research Clinical Lecturer in Rheumatology at the University of Leeds.
The session discussed new efficacy data regarding treatments, and how patients should be chosen for disease modifying antirheumatic drug (DMARD) therapy, as well as how to monitor outcomes.
“A lot of newer drugs focus on the IL-17 pathway, which is a different part of the immune system (than what previous drugs targeted) and which seems to be particularly important for psoriatic arthritis, psoriasis, and spondylitis arthritis,” Dr Coates said.
Reseachers examined the efficacy of secukinumab and ixekizumab, which are both biologic DMARDs that inhibit IL-17. IL-23 inhibitors are a biologic DMARD that target the same pathway, and are currently in clinical testing.
Significant promise has been found in an inhibitor of both IL-17 and TNF, the first of its kind, and JAK inhibitors, which act on a different pathway and are being evaluated in psoriatic arthritis.
There has been less new data regarding synthetic DMARDs, and there is a growing uncertainty about treating these patients with methotrexate. An analysis of randomized trials of methotrexate suggests that certain subsets of patients with psoriatic arthritis may benefit.
“I think that methotrexate works better for polyarthritis and probably for small joint arthritis rather than larger joints, but that is more experience-based than trial-based,” Dr Coates said.
Since there are no research-based guidelines to determine whether a patient should be treated with a biologic or synthetic DMARD, physicians typically base their decisions on the disease severity and what drugs the payer covers.
In the United States and Europe, most insurers require patients to fail to respond to synthetic DMARDs prior to covering biologic drugs.
Currently, there has been a shift towards a target-to-treat approach in managing this disease, which was previously discussed in another session
. This approach means that is a patient fails to meet an outcome with a certain treatment, the physician changes treatment to a higher dose, a combination of drugs, or switching them to a biologic.
“Treat-to-target results in changing treatment quicker if it is not working and aiming for a very high target of patients doing really well,” Dr Coates said.