ACR Convergence 2021—Alexis Ogdie, MD, associate professor of medicine and epidemiology at the University of Pennsylvania, Philadelphia, presented key principles of diagnosis and management of spondyloarthritides at the ACR Convergence session CARE: Spondyloarthritis.
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Dr. Ogdie began her presentation with an overview of the treat-to-target approach to psoriatic arthritis (PsA). She described the primary target as remission and the alternate target as low disease activity. The treat-to-target approach requires that rheumatologists objectively monitor disease, modify treatment to get to target and follow up on any changes in disease activity the patient experiences. This process should be guided by the 2018 ACR/National Psoriasis Foundation Guideline for the Treatment for Psoriatic Arthritis.1
Although the guideline states that the treat-to-target recommendation for patients with active PsA is conditional based on low-quality evidence, it nevertheless recommends following a treat-to-target strategy for most patients. The guideline does acknowledge, however, that such a strategy may not be appropriate for patients due to the risk of increased adverse events, costs of therapy and the burden imposed by medications and additional visits associated with tighter control.
The guideline recommends that the Disease Activity in Psoriatic Arthritis (DAPSA) or Minimal Disease Activity (MDA) score be used to assess treatment response. DAPSA includes a 68 tender joint count, 66 swollen joint count, patient global assessment of 0–10, patient pain of 0–10 and C-reactive protein (CRP) in mg/dL.
Dr. Ogdie pointed out that if the MDA is used to assess disease activity in patients with PsA, it should include assessment of swollen joints, tender joints, enthesitis, the Health Assessment Questionnaire (HAQ), patient global assessment, patient pain and psoriasis. A paper published after the guideline was released indicated that the Psoriatic Arthritis Impact of Disease (PsAID) questionnaire may be able to replace the HAQ, and, according to Dr. Ogdie, the PsAID is increasingly used by rheumatologists in Europe.2
The 2018 guideline also specifies that, in most cases, a treatment-naive patient with PsA should be prescribed tumor necrosis factor (TNF) inhibitors in preference to oral, small-molecule drugs. Other therapies may be used in special conditions (e.g., an interleukin 17 inhibitor in the setting of severe psoriasis).
Prior to treatment, however, it is important to ascertain if the patient has inflammatory bowel disease, said Dr. Ogdie. If the patient does have inflammatory bowel disease, rheumatologists should not prescribe drugs that are incompatible with the condition, and she emphasized the importance of heeding Boxed Warnings.