Psoriatic Arthritis: Which drug and when?

Bimlesh Dhar Pandey MD, MRCP
Consultant Rheumatologist, Fortis Hospital, Noida

Psoriatic disease, not just arthritis!

Psoriatic arthritis happens to be a dynamic disease and throws up lot of clinical challenges. The challenge is augmented by clinical heterogeneity, unpredictable clinical course, and treatment response. if we could dwell deep, one could sense that we poorly understand the disease from its genetics, clinically varied forms related to the skin, musculoskeletal and systemic effects. The first order of thought would be re-naming the whole spectrum as Psoriatic Disease and then subdividing into its clinically identifiable forms, say Psoriasis, Psoriatic Arthritis, Psoriatic Dactylitis, Psoriatic Spondylitis, Psoriatic Enthesitis. This is, as representative as, psoriasis labelled as guttate, plaque, inverse, erythrodermic psoriasis by dermatologists.

Personalised medicine in Psoriatic arthritis

The concept of personalised medicine in the management of psoriatic arthritis appears to be feasible. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis’ (GRAPPA) domain-based approach is scientific, practical and doable. The table below is a short summary of the same.

Domain Strongly recommended
Peripheral arthritis  csDMARDs, TNFi, IL-12/23i, IL-17i, IL-23i, JAKi, PDE4i
Axial Disease NSAIDs, physiotherapy, TNFi, IL-17i, JAKi
Enthesitis TNFi, IL-12/23i, IL-17i, IL-23i, JAKi, PDE4i
Dactylitis TNFi, IL-12/23i, IL-17i, IL-23i, JAKi, PDE4i
Psoriasis Topical therapies, phototherapy, csDMARDs, TNFi, IL-12/23i, IL-17i, IL-23i, PDE4i, JAKi
Nail psoriasis TNFi, IL-12/23i, IL-17i, IL-23i, PDE4i
IBD TNFi (not ETN), IL-12/23i
Uvietis TNFi (not ETN)

While GRAPPA proposes domain-based treatment, American College of Rheumatology (ACR) advocates radical treatment upfront and European Alliance of Associations for Rheumatology (EULAR) advises a relatively conservative approach. Despite inherit differences between them, they all propose low disease state or remission.

Can big data and artificial intelligence influence our approach?

It is a matter of time when the big data and artificial intelligence in medicine will be able to provide intelligent answers. This is possible with rapid strides of ever-expanding understanding of the disease at various levels like genetics, epigenetics, proteomics, metabolomics, lipidomics, transcriptomics, environmental triggers and gut dysbiosis. The integration of data on a common platform is the way forward.

Any research should address multiple disease domains

Amalgamating evidence, building consensus and generation of practical recommendations is gaining momentum. GRAPPA, ACR and EULAR have systematically collected evidence. It is aimed at disease remission/low disease state and preservation of quality of life. Additionally, the comprehensive assessment of the disease considering the multiple domains should be an essential guiding principle. The co-morbidities have influenced most of the present practical recommendations and the patient centric approach overrides the hierarchical approach of the past. The clinical trials and their design should use the GRAPPA-OMERACT core outcome measure set for assessment of PsA or such other tools as they address all of musculoskeletal disease activity, skin disease activity, pain, quality of life and inflammation.

We look forward to studies on drug combinations and more between drug class and head-to-head comparisons. The increase in treatment options is a welcome sign. The problem of plenty should address the fundamental question ‘which drug and when?’

Suggested reading:

  1. Coates LC, Soriano ER, Corp N, Bertheussen H, Callis Duffin K, Campanholo CB et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA): updated treatment recommendations for psoriatic arthritis 2021. Nat Rev Rheumatol. 2022 Aug;18(8):465-479.
  2. Miyagawa I, Tanaka Y. Dawn of Precision Medicine in Psoriatic Arthritis. Front Med (Lausanne). 2022 Mar 18;9:851892.
  3. Gurke R, Bendes A, Bowes J, Koehm M, Twyman RM, Barton A et al. Omics and Multi-Omics Analysis for the Early Identification and Improved Outcome of Patients with Psoriatic Arthritis. Biomedicines. 2022 Sep 24;10(10):2387.