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Panel revises spondyloarthritis treat-to-target recommendations

Publish date: June 23, 2017

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ASDAS makes sense but evidence needed

The evidence we now have is the difference between the new recommendations and the prior version. We have evidence from trials in patients with psoriatic arthritis using minimal disease activity as a target. And we have indirect evidence from observational studies in patients with SpA that suggest the higher the ASDAS, the more progression occurs. In addition, results reported at the EULAR 2017 Congress showed that reductions in the ASDAS appeared to correlate with the effect of a tumor necrosis factor inhibitor on reduced radiographic progression in patients with ankylosing spondylitis. But this is just an association; data from a randomized, prospective trial should be available next year.

^{Mitchell L. Zoler/Frontline Medical News}

Dr. Lianne S. Gensler

Although the data today are incomplete, I agree that the ASDAS is the best measure we have for disease activity in patients with axial SpA. Based on data reported at EULAR, it seems that an ASDAS of less than 1.3 is the right target for many axial SpA patients, although every patient has a different target that must be individualized. Every patient has a different risk and benefit agenda; the target must be very patient centered.

The recommendations say to manage patients with axial SpA or psoriatic arthritis by treating them to a target. To do that a clinician needs a standardized assessment of a patient’s disease and to perform follow-up measurements to see if the target is met. The data Dr. Dougados cited from Paris document that assessments such as an ASDAS are rarely made. Getting an ASDAS means knowing either a patient’s C-reactive protein level or erythrocyte sedimentation rate. That requires blood work before a clinic visit, something patients often don’t want.

Will these recommendations change practice and make the ASDAS more widely used? That depends to some extent on whether any benefits or penalties linked to ASDAS use go into place.

Next year, we expect to see results from trials that are testing whether the treat-to-target approach produces better outcomes. Evidence like that will be important to further spur adoption.

Lianne S. Gensler, MD , is director of the ankylosing spondylitis clinic at the University of California, San Francisco. She has been a consultant to Novartis and Janssen and has received research support from AbbVie and UCB. Dr. Gensler was a member of the task force that issued the revised recommendations. She made these comments in an interview.

EXPERT ANALYSIS FROM THE EULAR 2017 CONGRESS

MADRID – The newly revised recommendations from an unaffiliated, international expert panel on a treat-to-target approach for axial spondyloarthritis and psoriatic arthritis has one conspicuous feature that the prior recommendations lacked: evidence.

The first treat-to-target recommendations for spondyloarthritis (SpA) and psoriatic arthritis (PsA) from 2013 were based entirely on expert opinion (Ann Rheum Dis. 2014 Jan;73[1]:6-16), but in the new update 4 of the 11 recommendations now have an evidence base as well as a fifth recommendation for the part that pertains to PsA, Désirée van der Heijde, MD, said at the European Congress of Rheumatology.

^{Courtesy of EULAR}

Dr. Désirée van der Heijde

In 2013, “we had no evidence,” but enough new findings accumulated during 2011-2016 to now back up almost half of the recommendations, said Dr. van der Heijde, professor of rheumatology at Leiden (the Netherlands) University Medical Center and spokesperson for the revision task force.

Among the evidence-based recommendations, the most striking was a new formulation for how to measure disease activity. The new recommendations call the ASDAS (Ankylosing Spondylitis Disease Activity Score) the “preferred” disease activity measure for patients with axial SpA and cite both the DAPSA (Disease Activity Index for Psoriatic Arthritis) as well as minimal disease activity as “considered to define the target” when treating PsA.

“This recommendation just made it,” squeaking onto the list with a 52% vote of approval from the task force members, said Dr. van der Heijde. “It had the longest discussion,” with a significant minority of panelists taking a different view.

ASDAS shook out as the preferred measure for axial SpA because of evidence linking a patient’s ASDAS with syndesmophyte formation. “The idea is that by targeting ASDAS you should have better outcomes,” she explained.

^{Courtesy of EULAR}

Dr. Maxime Dougados

If ASDAS is to become the go-to assessment for managing axial SpA, then many more physicians will need to use it. Just before Dr. van der Heijde unveiled the revised recommendations, Maxime Dougados, MD, spoke about challenges in applying the treat-to-target strategy to axial SpA. One challenge is getting physicians to make the necessary assessments in routine practice. He cited data collected from 32 rheumatology practices in the Paris area showing that fewer than 1% of patients had undergone ASDAS assessment (Clin Exp Rheumatol. 2015 Nov/Dec;33[6]:851-7).

“Applying a treat-to-target approach in axial SpA is feasible but requires systematic collection of outcome parameters in daily practice,” such as ASDAS, said Dr. Dougados, professor of rheumatology at Cochin Hospital in Paris. Another piece currently lacking in the case for treat-to-target is demonstration of the clinical benefit from this approach in a trial, he added.

^{Courtesy of EULAR}

Dr. Jurgen Braun

Outcome measures of disease activity such as the ASDAS, as well as the Disease Activity Score 28 for rheumatoid arthritis, “are instrumental to reach the targets set” in a treat-to-target strategy, agreed Jürgen Braun, MD, professor of rheumatology and medical director of the Rheumatology Center in Herne, Germany, and another speaker during the session.

According to Dr. van der Heijde, the other four recommendations that now have evidence backup are:

Define clinical remission or minimal disease as the absence of clinical and laboratory evidence of significant disease activity.
An alternative treatment target for PsA may be low or minimal disease activity.
Measure disease activity by clinical signs and symptoms and by acute phase reactants.
Once a treatment target is reached it should be maintained.

The task force also outlined “an extensive research agenda” where evidence is needed, specifying close to 50 individual research topics. Among them Dr. van der Heijde particularly called out the role of the Health Assessment Questionnaire (HAQ), validation of PsA target outcomes, and better parsing of the differences using remission or low disease activity as the treatment target.

Dr. van der Heijde, Dr. Dougados, and Dr. Braun are all consultants for several drug companies.

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

Panel revises spondyloarthritis treat-to-target recommendations

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