Psoriatic arthritis (PsA) occurs in 6% to 41% of patients with psoriasis but goes frequently undiagnosed by dermatologists. However, earlier treatment initiation is beneficial. During a presentation at NAMCP 2020 Virtual Spring Managed Care Forum, Allan Gibofsky, MD, JD, MACR, FACP, FCLM, professor of medicine at Weill Cornell Medicine and attending rheumatologist at the Hospital for Special Surgery, discussed current treatment options and therapies being studied in the pipeline for this patient population.
Current treatment options include anti-tumor necrosis factor therapies (e.g., etanercept, infliximab, adalimumab, golimumab, and certolizumab), disease-modifying anti-rheumatic drugs, non-steroidal anti-inflammatory drugs, corticosteroids (oral or injectable), and non-pharmacologic measures (e.g., physical therapy, depression treatment, smoking cessation, etc.). There are also a number of newer targeted agents that can be used, such as ustekinumab, secukinumab, abatacept, apremilast, ixekizumab, and tofacitinib.
Dr. Gibofsky also noted that there are other targeted therapies in development, including brodalumab, guselkumab, risankizumab, and tildrakizumab. A 2014 study published in The New England Journal of Medicine found that brodalumab improved American College of Rheumatology (ACR) 20 scores compared with placebo at both 12 and 24 weeks. A 2018 phase IIa study published in The Lancet showed that guselkumab significantly improved ACR20 (P<0.001) and psoriasis area and severity index (PASI) 75 score (P<0.001) compared with placebo. A 2016 phase II study published in Annals of Rheumatic Diseases found that tildrakizumab improved PASI 75 compared with placebo. There was also a trend toward improved visual analog scale pain scores, Health Assessment Questionnaire scores, PsA screening and evaluation, and high-sensitivity C-reactive protein with tildrakizumab.
When managing patients with PsA, Dr. Gibofsky encouraged communication that maintains patient motivation and engagement in care, understands and explores reasons for adherence decline, provides realistic expectations, and takes a health literacy approach to prescribing and education.
Shared decision-making should be a collaborative process that defines a set of medically reasonable options and explains and contrasts their open attributes. Talk to patients about what outcomes are of most importance to them to help make a treatment decision. Shared decision-making should be conducted as an interviewing technique in which the clinician shares factors about treatment benefits, harms, procedures, and costs, while the patients shares their values and preferences about treatment attributes. A decision should be mutually agreed upon or deferred pending further information or longer deliberation.
Still, making a treatment decision can be challenging, as it requires sharing a robust amount of information that needs to be simplified and tailored to the patient’s health literacy level. Besides health literacy, age and general health, economic status, and value of the information can impact patient adherence to treatment. Decision aids, support personnel, and follow-up office visits or phone coaching can be used during the decision-making process.
Presentation: Recent Developments in the Treatment and Management of Psoriatic Arthritis. NAMCP 2020 Virtual Spring Managed Care Forum, April 16-17.