PARK CITY, UTAH – Since most people with psoriatic arthritis (PsA) develop psoriasis before joint symptoms, it’s helpful to have a simple screening test for the condition.
One of Dr. Philip Mease’s favorite PsA screening tools is the Psoriasis Epidemiology Screening Test (PEST), which was first described at the 2009 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) and consists of five simple questions. They are: Have you ever had a swollen joint (or joints)? Has a doctor ever told you that you have arthritis? Do your fingernails or toes have holes or pits? Have you had pain in your heel? Have you had a finger or toe that was completely swollen and painful for no apparent reason? (Clin Exp Rheumatol. 2009;27:469-74).
Dr. Philip Mease
“Just these five simple questions, or trying to remember a few of them, can help you in your review of systems,” Dr. Mease, director of arthritis research at Swedish Medical Center, Seattle, said at the annual meeting of the Pacific Dermatologic Association. “I think patients appreciate it when you look beyond the skin in your questioning. These can pick up [PsA] with a high sensitivity and specificity” of 0.92 and 0.78, respectively.
He went on to discuss current PsA treatment approaches. According to an evidence review that he and his associates in GRAPPA published in 2009, biologics (anti–tumor necrosis factor inhibitors) as a group were found to be effective in all five domains of the disease: peripheral arthritis, skin and nail disease, axial disease, dactylitis, and enthesitis, while the oral disease-modifying antirheumatic drugs (DMARDs) were effective for peripheral arthritis and skin and nail disease.
Other treatments that were found effective are: psoralen and UVA/UVB for skin and nail disease, physiotherapy for axial disease, intra-articular steroids for peripheral arthritis, and NSAIDs for peripheral arthritis and axial disease (J Rheum. 2009;33:1417-21). “Patients with mild disease can be tried on NSAIDs, especially in a patient with monoarticular disease, but for the most part we need to move on to using systemic medication,” he said. Updated recommendations from GRAPPA include new data regarding ustekinumab, apremilast, and secukinumab, as well as data on comorbidities (J Rheumatol. 2015;42[6]:1052-5).
According to Dr. Mease, controlled trials of DMARDs in PsA patients have yielded treatment effects that range from marginal in the joints to marginal or none at all in the skin. Data from the Methotrexate in Psoriatic Arthritis trial conducted in the United Kingdom and published in 2012 showed no evidence that methotrexate improves inflammatory synovitis in active PsA (Rheumatol. 2012;51:1368-77).
“There were issues with this trial, including the fact that it took 5 years to enroll patients, and many dropped out, so I don’t think it’s a very reliable study,” said Dr. Mease, who is also a professor of medicine in the division of rheumatology at the University of Washington, Seattle. “Currently, Amgen is in the process of starting a trial in which the goal is to enroll 840 subjects with early PsA who are being randomized to methotrexate alone, Enbrel alone, or Enbrel plus methotrexate. This, I think, is going to give us a better answer about the effectiveness of methotrexate. It will also teach us about whether there’s a value in combining an anti-TNF inhibitor with methotrexate. We still don’t know the answer to that question.”
The most recent data on methotrexate come from an open-label trial known as TICOPA, which used a tight control treatment paradigm through 48 weeks of treatment. A subanalysis of 188 patients treated with methotrexate through 12 weeks was presented at the 2015 meeting of the European League Against Rheumatism. It revealed that 41% of patients achieved an ACR 20, 22% achieved minimal disease activity, 62% experienced an improvement in dactylitis, and 25% experienced an improvement in enthesitis.
“So we have a few data suggesting that methotrexate may be modestly effective in treating PsA,” Dr. Mease said. “We often will start with methotrexate unless the patient has really aggressive disease activity. If they get some effect from the drug but not enough, we’ll often add a biologic agent but often keep some methotrexate in the background, even at 10 mg per week, in order to reduce immunogenicity from a biologic.”
Dr. Mease disclosed that he has received research grants, consultation fees, and/or speaker honoraria from AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, Genentech, GlaxoSmithKline, Janssen, Eli Lilly, Merck, Novartis, Pfizer, and UCB.