Can Treat-to-Target Help Reach Remission in PsA?
The complexity of psoriatic arthritis makes remission a challenging goal.
Treat-to-target (T2T) is such a hot topic in medicine it should have its own hashtag. It began as a strategy for managing diabetes and heart disease and is now the most widely accepted treatment approach for rheumatoid arthritis (RA) and other inflammatory diseases. But experts say T2T can be more complex for people with psoriatic arthritis (PsA).
In T2T, medications are adjusted over time to reach a pre-determined treatment goal. The ultimate aim is achieving remission (the absence of signs or symptoms of disease activity). But if you have long-standing disease, low disease activity – meaning there are very few signs of disease – is an acceptable goal.
Depending on your disease activity and overall health, monitoring can occur as frequently as monthly, or less frequently (such as every 3–6 months). At each office visit, you are evaluated to see if you’ve reached the goal. If not, medication dose is increased, new drugs are added or you may be switched to a different drug class. The process continues, using increasingly aggressive therapies, until you come as close to remission or low disease activity as possible.
Although many of the drugs used for RA are also used to treat psoriatic arthritis, T2T is not the standard of care in PsA like it is in RA, says Philip Mease, MD, a clinical professor at the University of Washington School of Medicine in Seattle. Dr. Mease is also a founder and past president of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), an international organization of rheumatologists and dermatologists.
He explains that PsA is a more complicated disease. It has at least five distinct domains: joints, spine, skin and nail disease, dactylitis (a sausage-like swelling of the fingers or toes) and enthesitis (inflammation where tendons and ligaments attach to bone). Most patients don’t have symptoms in every domain, but each must be taken into account when formulating treatment targets, says Soumya Reddy, MD, an assistant professor of medicine and co-director of the Psoriatic Arthritis Center at New York University Langone Medical Center.
“If we tailor treatments just to joint pain but they’re not effective for the skin, then the patient is not having a good outcome,” she says. That’s important because there doesn’t seem to be much correlation between improvement in one domain of PsA and improvement in others.
T2T Put to the Test
Another challenge in developing targets for PsA is a lack of good data. Results of the only clinical trial to assess T2T in PsA – the Tight Control of Psoriatic Arthritis (TICOPA) Trial – were published in The Lancet in late 2015. In the trial, 206 patients with early PsA were randomized to receive standard care or tight control/management for 48 weeks.
The tight control group saw their doctors once a month. Using pre-determined targets and a specific protocol, they were treated with disease-modifying antirheumatic drugs (DMARDs) using minimal disease activity (MDA) as the goal. The standard care patients were seen once every 12 weeks, and were treated as deemed appropriate by their doctor with no set protocol to guide their treatment regimen.
Results showed that skin and joint symptoms and patient-reported outcomes improved significantly in the group using MDA as the treatment target. The study authors didn’t choose remission (defined as no symptoms across all PsA domains) as a target because, they said, “it’s hard to achieve.” MDA was an easier goal. Patients in the trial were considered to have achieved MDA if they met five of seven criteria, including having few or no swollen and tender joints and very little skin involvement, pain or disability.
But Dr. Mease points out that trial criteria can be tricky to implement in clinical practice.
“In the TICOPA trial, if a patient was very close to achieving MDA in five of the seven categories – just on the threshold but not quite there – the clinician was forced to tweak the therapy, either by intensifying the dose or switching to anti-TNF [anti-tumor necrosis factor] therapies. This showed a statistically superior improvement in symptoms, but also a significant increase in adverse events,” he says.
What Matters to Patients
Dr. Mease helped develop GRAPPA’s updated PsA management recommendations, which were published in Arthritis & Rheumatology in May 2016. The guidelines include evidence-based recommendations for each of PsA’s key domains, but even Dr. Mease says there’s more to managing PsA than treatment goals.
“It’s good to shoot for minimal disease or remission, but you also have to take into account how patients look and feel – whether they are more functional and productive,” says Dr. Mease. “It’s essential to have conversations about what matters most to them. If someone has a patch of severe psoriasis or very bad nail disease and is working in the jewelry department at Nordstrom, then treating those symptoms is more important to that patient than treating knee inflammation. That’s the beauty of the conversation; patients are able to prioritize what is most important to them and hopefully the rheumatologist will track that issue from visit to visit.”
Arthur Kavanaugh, MD, a professor of clinical medicine at the University of California, San Diego, and a GRAPPA member, notes that although treatment choices may be “patient driven,” the benefits and harms of any therapy need to be weighed.
“Regular assessment of patients and getting them to a goal makes sense, but we also have to ask how hard we should push because we [need to be sure] what the benefits will be,” he says.
The doctors say about 40% of patients with PsA can expect to achieve minimal disease activity.
“Although that’s pretty good, we would like it to be 100%, of course,” Dr. Kavanaugh says. “We would also love to see patients in remission, but if the definition of remission is no activity across all PsA domains, then that is harder to achieve.”