Ideal target for psoriatic arthritis? Comparison of remission and low disease activity states in a real-life cohort

Background Psoriatic arthritis (PsA) recommendations state that the target of treatment should be remission or Low disease activity (LDA). We used a real life dataset to compare different potential targets. Methods 250 PsA patients considered in an acceptable disease state according to their rheumatologist were included. Targets for remission were the DAPSA and cDAPSA remission (≤4), VLDA and PASDAS ≤ 1.9. LDA targets analyzed were the DAPSA ≤14, clinical cDAPSA ≤13, MDA, adjusted MDA targets: MDAjoints with both TJC and SJC mandated, MDAskin(PASI mandated), MDAjoints&amp;skin; with TJC, SJC and PASI mandated. Results Comparison of the several candidate targets demonstrates that VLDA is achieved by the lowest proportion of patients and includes patients with the lowest residual disease activity compared with the other remission targets. The modified MDA measures are the most stringent targets for low disease activity in terms of residual disease on joints, psoriasis and enthesitis within patients achieving the target. In both remission and LDA, the inclusion of CRP did not show an added value. The exclusion of a skin domain, as in the DAPSA measures, resulted in negligence of skin disease and a negative impact on the QoL in some patients. Conclusions The different remission and LDA targets show us significant overlap between measures but these measures targeting the same definition do differ in terms of allowance of residual disease. Inclusion of laboratory markers seems unnecessary although exclusion of a skin domain may result in psoriasis not being assessed resulting in residual impactful skin disease. </p

Response to: 'To DAPSA or not to DAPSA? That is not the question' by Schoels et al.

We thank the authors for the interest in our paper and are grateful for the opportunity to respond to the points raised1. We agree that there is a clear distinction between composite measures of psoriatic arthritis such as DAPSA and composite measures of psoriatic disease such as MDA/VLDA and PASDAS. As the Vienna group rightly point out, these measures differ in terms of the components included, but not due to disagreement within the outcome measure community as suggested in the letter. The choice of components for each composite measure was decided using different methodology in the development of each one, thus resulting in different measures. We believe that this variation in scores is one reason for the need to compare such scores in different populations to establish the optimal measure or measures for PsA. Indeed when the DAPSA was originally suggested, it was because the same components used in the DAREA were identified in a principal component analysis (PCA) in PsA. Interestingly in this analysis, the variables tested were taken from the OMERACT PsA domains and therefore DAPSA was not, a priori, designed specifically to be a unidimensional composite measure. The fourth component identified in the PCA was the PASI highlighting the importance of skin in PsA despite the fact that patients had a low baseline mean PASI of only 3.3. Whilst PASI was not included in the DAPSA as the eigenvalue was 0.949 and therefore just under the threshold of 12, it is interesting to imagine how the results may have differed if it were developed in a group with slightly more active skin disease

Ideal target for psoriatic arthritis? Comparison of remission and low disease activity states in a real-life cohort

Background Psoriatic arthritis (PsA) recommendations state that the target of treatment should be remission or Low disease activity (LDA). We used a real life dataset to compare different potential targets. Methods 250 PsA patients considered in an acceptable disease state according to their rheumatologist were included. Targets for remission were the DAPSA and cDAPSA remission (≤4), VLDA and PASDAS ≤ 1.9. LDA targets analyzed were the DAPSA ≤14, clinical cDAPSA ≤13, MDA, adjusted MDA targets: MDAjoints with both TJC and SJC mandated, MDAskin(PASI mandated), MDAjointsandskin with TJC, SJC and PASI mandated. Results Comparison of the several candidate targets demonstrates that VLDA is achieved by the lowest proportion of patients and includes patients with the lowest residual disease activity compared with the other remission targets. The modified MDA measures are the most stringent targets for low disease activity in terms of residual disease on joints, psoriasis and enthesitis within patients achieving the target. In both remission and LDA, the inclusion of CRP did not show an added value. The exclusion of a skin domain, as in the DAPSA measures, resulted in negligence of skin disease and a negative impact on the QoL in some patients. Conclusions The different remission and LDA targets show us significant overlap between measures but these measures targeting the same definition do differ in terms of allowance of residual disease. Inclusion of laboratory markers seems unnecessary although exclusion of a skin domain may result in psoriasis not being assessed resulting in residual impactful skin disease. </p

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

Objective This literature review aimed to identify the most efficacious current interventions for dactylitis and provide up-to-date scientific evidence to support the 2021 Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) recommendations on the management of psoriatic arthritis. Methods Original articles published from 2013 to 2020, registered in MEDLINE, Embase, and Cochrane Library, describing interventional trials and reporting dactylitis-related outcomes were included. The 20 members of the GRAPPA dactylitis group were divided into 9 subgroups according to treatment, and members of each group independently extracted data from articles/abstracts corresponding to their group by using a standardized data extraction form. Results Forty-nine publications were analyzed, representing 40 randomized clinical trials (RCTs) and including 16,752 patients. Dactylitis was assessed as a secondary outcome in 97.5% of these trials and more than 40% of RCTs did not employ a specific dactylitis measure or instrument. Conclusion The emergence of agents with novel mechanisms of action in recent years, such as interleukin 17 (IL-17), IL-12/23, IL-23, and Janus kinase inhibitors, has significantly expanded the available treatment options for dactylitis. This article points out the lack of consensus regarding dactylitis assessment and the paucity of data concerning the effect of local steroid injections, nonsteroidal antiinflammatory drugs, and conventional disease-modifying antirheumatic drugs. Clinical trials evaluating the effect of these traditional and low-cost medications used to treat dactylitis should be encouraged

Management of dactylitis in patients with psoriatic arthritis: an updated literature review informing the 2021 GRAPPA treatment recommendations

Objective This literature review aimed to identify the most efficacious current interventions for dactylitis and provide up-to-date scientific evidence to support the 2021 Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) recommendations on the management of psoriatic arthritis. Methods Original articles published from 2013 to 2020, registered in MEDLINE, Embase, and Cochrane Library, describing interventional trials and reporting dactylitis-related outcomes were included. The 20 members of the GRAPPA dactylitis group were divided into 9 subgroups according to treatment, and members of each group independently extracted data from articles/abstracts corresponding to their group by using a standardized data extraction form. Results Forty-nine publications were analyzed, representing 40 randomized clinical trials (RCTs) and including 16,752 patients. Dactylitis was assessed as a secondary outcome in 97.5% of these trials and more than 40% of RCTs did not employ a specific dactylitis measure or instrument. Conclusion The emergence of agents with novel mechanisms of action in recent years, such as interleukin 17 (IL-17), IL-12/23, IL-23, and Janus kinase inhibitors, has significantly expanded the available treatment options for dactylitis. This article points out the lack of consensus regarding dactylitis assessment and the paucity of data concerning the effect of local steroid injections, nonsteroidal antiinflammatory drugs, and conventional disease-modifying antirheumatic drugs. Clinical trials evaluating the effect of these traditional and low-cost medications used to treat dactylitis should be encouraged

Physician’s Global Assessment in Psoriatic Arthritis: A Multicenter GRAPPA Study

Objective: Physician’s global assessment (PGA) of disease activity is a major determinant of therapeutic decision making. This study assesses the reliability of the PGA, measured by means of 0–100 mm visual analog scale (VAS), and the additional use of separate VAS scales for musculoskeletal (PhysMSK) and dermatologic (PhysSk) manifestations in patients with psoriatic arthritis (PsA). Methods: Sixteen centers from 8 countries enrolled 319 consecutive patients with PsA. PGA, PhysMSK, and PhysSk evaluation forms were administered at enrollment (W0) and after 1 week (W1). Detailed clinical data regarding musculoskeletal (MSK) manifestations, as well as dermatological assessment, were recorded. Results: Comparison of W0 and W1 scores showed no significant variation (intraclass correlation coefficients were PGA 0.87, PhysMSK 0.86, PhysSk 0.78), demonstrating the reliability of the instrument. PGA scores were dependent on PhysMSK and PhysSk (p < 0.0001) with a major effect of the MSK component (B = 0.69) compared to skin (B = 0.32). PhysMSK was correlated with the number of swollen joints, tender joints, and presence of dactylitis (p < 0.0001). PhysSk scores were correlated with the extent of skin psoriasis and by face, buttocks or intergluteal, and feet involvement (p < 0.0001). Finally, physician and patient assessments were compared showing frequent mismatch and a scattered dot plot: PGA versus patient’s global assessment (r = 0.36), PhysMSK versus patient MSK (r = 0.39), and PhysSk versus patient skin (r = 0.49). Conclusion: PGA assessed by means of VAS is a reliable tool to assess MSK and dermatological disease activity. PGA may diverge from patient self-evaluation. Because MSK and skin/nail disease activity may diverge, it is suggested that both PhysMSK and PhysSk are assessed