Although remission is the ultimate goal for patients with psoriatic arthritis (PsA) and their physicians, there are many unanswered questions regarding what precisely we should aim to achieve, according to the results of a recent review published in Rheumatology (Oxford).1

Recent advances in the pharmacologic treatment of and therapeutic strategies for PsA have resulted in improved responses in many patients, and targeting remission as a treatment goal is becoming a reality. Treat-to-target is an approach that focuses on maximizing benefits, regardless of the type of medication used, by monitoring disease activity and using the results to guide treatment choices. The measurement of treatment response among patients with PsA has generated much debate among the experts over the years, with many different tools available for disease assessment. Comparisons of the different types of measures, along with their varying strengths and weaknesses, is ongoing.

Evidence supporting the use of treat-to-target strategies in patients with PsA began to emerge in 2013, with many therapies and outcome measures being borrowed from the rheumatoid arthritis arena. Advancements in imaging techniques have the potential to improve the management of PsA and provide outcomes for remission. The use of magnetic resonance imaging, ultrasound, and computed tomography scans in the study of PsA has led to an improved understanding of the various PsA phenotypes.

Remission is achieved when a patient’s inflammatory disease process is controlled (ie, no symptoms and absence of long-term functional or structural joint consequences).2 PsA is a multifaceted disease with a variety of rheumatologic and dermatologic presentations. PsA not only has clinical manifestations, but the disease is also characterized by structural and immunologic changes.


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Patients with PsA and their physicians often view the disease quite differently, and a discrepancy exists between patient and physician assessment of joint activity.3 Patient education in PsA is often not ideal, and patients with the disease are typically less empowered than those with rheumatoid arthritis.4

Two theories have been proposed for the pathogenesis of PsA: classic autoimmune etiology or microtrauma at the enthesis leading to innate immune events.5 Improved understanding of the key pathologic pathways that drive disease progression from skin to bone involvement is needed to develop more effective therapeutic strategies and identify specific biomarkers for the disease.

The authors of the review concluded that, although targets for response in PsA have been discussed extensively, little evidence is available to guide consensus. Disease remission remains the ultimate goal for patients with PsA and the physicians who treat them.

References

  1. Coates LC, Conaghan PG, D’Agostino MA, et al. Remission in psoriatic arthritis—where are we now? [published online October 16, 2017]. Rheumatology (Oxford). doi: 10.1093/rheumatology/kex344
  2. Kavanaugh A, Fransen J. Defining remission in psoriatic arthritis. Clin Exp Rheumatol. 2006;24(6 suppl 43):S-83-S-87.
  3. Eder L, Thavaneswaran A, Chandran V, Cook R, Gladman DD. Factors explaining the discrepancy between physician and patient global assessment of joint and skin disease activity in psoriatic arthritis patients. Arthritis Care Res (Hoboken). 2015;67(2):264-272.
  4. Helliwell P, Coates L, Chandran V, et al. Qualifying unmet needs and improving standards of care in psoriatic arthritis. Arthritis Care Res (Hoboken). 2014;66(12):1759-1766.
  5. FitzGerald O, Haroon M, Giles JT, Winchester R. Concepts of pathogenesis in psoriatic arthritis: genotype determines clinical phenotype. Arthritis Res Ther. 2015;17:115.