Treatment Continuation Guidance in Psoriatic Arthritis Clinical Care

Psoriatic arthritis (PsA) has many disease manifestations leading to diverse patient phenotypes. Treatment responses in the same individual may diverge for concomitantly active PsA components. For this reason, evaluation of disease activity and treatment effectiveness for PsA should ideally include assessment of the complete spectrum of manifestations: psoriasis of skin and nails, arthritis, enthesitis, dactylitis, axial spondyloarthritis (SpA), systemic inflammation, and effect on life. Signs of active disease could then be systematically addressed for each individual. Comprehensive PsA assessment is often challenging in clinical practice because of limitations on time and resources for rheumatology clinic visits. However, clinicians are uniformly confronted with effectiveness questions when treating PsA: Is the treatment working? Is it time to switch therapies? Which treatment should be next? Cañete, et al , as described in this issue of The Journal 1, conducted a consensus exercise to define the effectiveness of biological disease-modifying antirheumatic drugs (bDMARD) and to support PsA treatment continuation decisions in clinical care. The study addresses a few scenarios relevant to clinicians such as disease severity or prior damage, peripheral and axial disease, and prior biologic experience. Criteria for bDMARD continuation are met in both peripheral and axial PsA if low disease activity (LDA) state and meaningful improvement [score improvement ≥ 3 in Psoriatic Arthritis Impact of Disease (PsAID)]2 have concomitantly been achieved (Table 1). The alternative continuation criteria, however, allow high or moderate disease activity in patients with severe PsA/damage/multiple biologic failures, as long as a major response to therapy and a patient acceptable symptom state in the PsAID (score ≤ 4) have concomitantly been achieved (Table 1). Because these effectiveness criteria define the lowest threshold for continuation of the treatment in the course in clinical care, they may shape PsA treatment and progression in the future. Comparing treatment strategies becomes … Address correspondence to Dr. A.M. Orbai, Johns Hopkins University School of Medicine, Division of Rheumatology, 5200 Eastern Ave., MFL Center Tower, Suite 4100, Baltimore, MD 21224, USA. Email: aorbai1{at}jhmi.edu.

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