SAN DIEGO – Compared with standard care, intensive management of psoriatic arthritis using a treat-to-target approach significantly improved joint and skin outcomes for patients newly diagnosed with the disease, results from a multicenter, randomized controlled trial showed.
"Treating to target works in this disease, and it’s going to result in better long-term outcomes," lead investigator Dr. Philip Helliwell said during a press briefing at the annual meeting of the American College of Rheumatology.
Dr. Philip Helliwell
Dr. Helliwell and his associates at eight centers in the United Kingdom randomized 206 patients with early psoriatic arthritis to standard care or intensive management, and followed them for 48 weeks. Patients in the standard care group were treated by a rheumatologist with no set protocol and no limitations, while those in the intensive management group followed a strict treatment protocol with escalation of therapy if minimal disease activity criteria were not met.
Patients in the intensive management group were started on methotrexate with rapid escalation to a dose of *25 mg/week after 6 weeks if they tolerated the drug. If they did not meet minimal disease criteria after 12 weeks, they received a more powerful combination of disease-modifying antirheumatic drugs (DMARDs).
After another 12 weeks, patients in the intensive management group were given anti–tumor necrosis factor therapy if they had three or more tender joints. If they had fewer than three tender or swollen joints but did not meet the minimal disease activity criteria, they were given methotrexate and an alternative DMARD. Patients in the standard care group were treated with DMARDs, but with no set time limits for drug therapy escalation or measurements to reach.
The primary outcome measures were the proportion of patients in both groups who achieved ACR20, ACR50, and ACR70 criteria for disease activity, which represent disease improvement of 20%, 50%, and 70%, respectively. Dr. Helliwell reported that compared with the standard care group, a higher proportion of patients in the intensive management group achieved ACR20 (62% vs. 45%, respectively), ACR50 (51% vs. 25%), and ACR70 (38% vs. 17%). A higher proportion of patients in the intensive management group also achieved a Psoriasis Area and Severity Index 75 compared with their counterparts in the standard care group (59% vs. 33%).
Research in psoriatic arthritis has "lagged behind that of rheumatoid arthritis for years in terms of pathogenesis and treatment paradigms," noted Dr. Helliwell, a senior lecturer in rheumatology at the Institute of Rheumatic and Musculoskeletal Medicine at the University of Leeds (England). "I think the study we’ve reported brings psoriatic arthritis right up to date alongside RA."
He said that up to one-third of people with psoriasis will develop psoriatic arthritis, "so it’s not an insignificant arthritis. It’s often not recognized. One survey we did of people with psoriasis in the community in the U.K. found that up to half of the people with psoriatic arthritis didn’t know they had it. They’d seen their doctor for various reasons and had been told they’d had another form of arthritis, or they were fobbed off with other diagnoses."
The researchers have yet to perform a cost analysis comparing the two treatment groups.
The study was funded by Arthritis Research UK and Pfizer. Dr. Helliwell disclosed that he has received consulting fees from Pfizer.
*Correction 11/11/13: A previous version of this story misstated the methotrexate dosage used in the study. This version has been updated to reflect the correct dosage.