Psoriatic arthritis can be more effectively treated through a treat-to-target approach, significantly improving joint outcomes for patients newly diagnosed with the condition, according to a study published in The Lancet.

In an open-label, multicenter, randomized, controlled trial conducted between 2008 and 2012, researchers assessed 206 patients with psoriatic arthritis. Eligible patients were aged 18 years and older, had early psoriatic arthritis with symptom duration of less than 24 months, and had not previously received treatment with antirheumatic drugs. Patients were enrolled in 8 secondary care rheumatology centers throughout the United Kingdom and were randomly assigned to either tight control or standard care groups.

“Observational studies have suggested that control of disease inflammation in psoriatic arthritis leads to improved long-term outcomes,” wrote senior author Laura C. Coates, MRCP, of the Leeds Institute of Rheumatic and Musculoskeletal Medicine at the University of Leeds in Leeds, United Kingdom. “More recent data suggest better outcomes in patients who are referred and treated earlier.  This evidence…was the impetus to study the effect of tight control of early psoriatic arthritis in a randomized controlled trial using a treat-to-target approach: the Tight Control of Psoriatic Arthritis (TICOPA).”

Patients in the tight-control group (101 patients, 49%) were seen every 4 weeks, treated according to a predefined treatment protocol, and assessed at each visit using the minimal disease activity (MDA) criteria. If patients had not achieved MDA, treatment with disease-modifying anti-rheumatic drugs (DMARDs) was increased.


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Patients in the standard-care group (105 patients, 51%) were treated at a general rheumatology outpatient clinic supervised by a consultant rheumatologist. These patients were assessed every 12 weeks, with no formal measures of disease activity used in clinical decision making.

In both groups, patients underwent radiographs of their hands and feet at baseline and 48 weeks, then scored according to a modified Sharp-van der Heijde scoring method for psoriatic arthritis. Baseline characteristics were similar across both treatment groups.  

The TICOPA trial primary end point was the proportion of patients in each treatment group achieving an American College of Rheumatology 20% response (ACR20) at 48 weeks.

At the conclusion of the study, 89% of patients receiving tight control and 88% of patients receiving standard care completed both treatment and follow-up. The researchers determined that the odds of achieving an ACR20 response were higher in the tight-control group than in the standard-care group (odds ratio [OR] 1.69; 95% confidence interval [CI], 1.10-2.60; P=.0158), and the odds of achieving ACR20 significantly increased over time (OR 1.02; 95% CI, 1.01-1.03; P=.0009). In the evaluable patient population (n=173),  Dr Coates and colleagues found that at 48 weeks, a greater number of patients in the tight-control group achieved an ACR20 response compared with the standard-care group (17.8% difference; 95% CI, 3.1-32.4; P=.0194).

“This study is the first to show that a treat-to-target approach can improve clinical outcomes for patients with early psoriatic arthritis,” wrote Dr Coates. “Although a 20% improvement in the ACR response criteria is equivalent to only a modest clinical benefit, a 50% to 70% improvement is very noticeable by the patient.”

References

  1. Coates LC, Moverley AR, McParland L, et al. Effect of tight control of inflammation in early psoriatic arthritis (TICOPA): a UK multicentre, open-label, randomized controlled trial. Lancet. 2015. doi: 10.1016/S00140-6736(15)00347-5.
  2. Gladman DD. Is it time for treat to target in psoriatic arthritis? Lancet. 2015. doi: 10.1016/S0140-6736(15)003484-7.