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

Report of the Skin Research Working Groups from the GRAPPA 2017 Annual Meeting.

At the 2017 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), the International Dermatology Outcome Measures (IDEOM) psoriasis working group presented an overview of its cutaneous domain of psoriatic arthritis (PsA) projects. First, the group presented an overview of IDEOM's work to establish psoriasis outcome measures that satisfy the needs of all those involved. Second, the group discussed replacements for the Psoriasis Area and Severity Index (PASI) that can be used in clinical practice, including data that support the use of the physician's global assessment × body surface area measurement score as a PASI surrogate. Third, the group discussed the contribution of skin disease to composite measures of PsA. Last, the group summarized the National Psoriasis Foundation's efforts to establish treat-to-target strategies for psoriasis care

Group for Research and Assessment of Psoriasis and Psoriatic Arthritis/Outcome Measures in Rheumatology consensus‐based recommendations and research agenda for use of composite measures and treatment targets in psoriatic arthritis

Background Many composite disease activity measures and targets have been developed for psoriatic arthritis (PsA). This GRAPPA-OMERACT work stream aimed to further the development of consensus among physicians and patients. Methods Prior to the meeting, physicians and patients were surveyed on outcome measures. A consensus meeting (26 rheumatologists, dermatologists, and patient representatives) reviewed evidence on composite measures and potential treatment targets, plus survey results. After discussions, participants voted on proposals for use and consensus was established in a second survey. Results Survey results from 128 HCPS and 139 patients were analysed alongside a SLR summarising evidence. A weighted vote was cast for composite measures (for RCTs, most popular measures were PASDAS [40 votes] and GRACE [28 votes]; for clinical practice, most popular were 3-VAS [45 votes], DAPSA [26 votes]). After discussion there was no consensus on a composite measure. The group agreed that several composite measures could be used. Future studies should allow further validation and comparison. The group unanimously agreed that remission should be the ideal target with minimal/low disease activity a feasible alternative. The target should include assessment of musculoskeletal disease, skin and health related quality of life. The group recommended a target of treatment as VLDA, or MDA. Conclusions Consensus was not reached on a continuous measure of disease activity. In the interim the group recommends several composites. Consensus was reached on a treatment target of VLDA/MDA. An extensive research agenda was composed and recommends that data on all PsA clinical domains be collected in ongoing studies.</p

Group for Research and Assessment of Psoriasis and Psoriatic Arthritis/Outcome Measures in Rheumatology Consensus-Based Recommendations and Research Agenda for Use of Composite Measures and Treatment Targets in Psoriatic Arthritis

Objective A meeting was convened by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and Outcome Measures in Rheumatology (OMERACT) to further the development of consensus among physicians and patients regarding composite disease activity measures and targets in psoriatic arthritis (PsA). Methods Prior to the meeting, physicians and patients completed surveys on outcome measures. A consensus meeting of 26 rheumatologists, dermatologists, and patient research partners reviewed evidence on composite measures and potential treatment targets plus results of the surveys. The meeting consisted of plenary presentations, breakout sessions, and group discussions. International experts including members of GRAPPA and OMERACT were invited to the meeting, including the developers of all of the measures discussed. After discussions, participants voted on proposals for use, and consensus was established in a second survey. Results Survey results from 128 health care professionals and 139 patients were analyzed alongside a systematic literature review summarizing evidence. A weighted vote was cast for composite measures. For randomized controlled trials, the most popular measures were the PsA disease activity score (40 votes) and the GRAPPA composite index (28 votes). For clinical practice, the most popular measures were an average of scores on 3 visual analog scales (45 votes) and the disease activity in PsA score (26 votes). After discussion, there was no consensus on a composite measure. The group agreed that several composite measures could be used and that future studies should allow further validation and comparison. The group unanimously agreed that remission should be the ideal target, with minimal disease activity (MDA)/low disease activity as a feasible alternative. The target should include assessment of musculoskeletal disease, skin disease, and health‐related quality of life. The group recommended a treatment target of very low disease activity (VLDA) or MDA. Conclusion Consensus was not reached on a continuous measure of disease activity. In the interim, the group recommended several composites. Consensus was reached on a treatment target of VLDA/MDA. An extensive research agenda was composed and recommends that data on all PsA clinical domains be collected in ongoing studies