HHE Rheumatology and musculoskeletal supplement 2018 | Page 7

Choosing the appropriate treatment
in each patient
The current treatment armamentarium for PsA
encompasses different drug classes, including
non-steroidal anti-inflammatory (NSAIDs),
conventional disease modifying anti-rheumatic
rugs (cDMARDs) and biologics (bDMARDs),
as well as small molecules. However, despite the
increasing availability of therapeutic strategies,
we rely on PsA clinical features to choose the
most appropriate treatment, 25 there are few
objective measurements, that is, CRP, to measure
its efficacy. 8 For patients with mild oligoarticular
presentation, NSAIDs and intra-articular
injections can be effective, but in patients with
more severe symptoms, cDMARDs are typically
prescribed as the initial treatment. Unfortunately,
there are limited data from randomised clinical
trials for cDMARDs in PsA, and their efficacy
is mostly suggested by rheumatoid arthritis
studies. A small real-life study suggested that
methotrexate (MTX), sulfasalazine (SSZ), and
leflunomide are effective in reducing peripheral
arthritis and enthesitis, while SSZ use is
associated with the greatest improvements. 26
Moreover, a randomised clinical trial on MTX
did not show a significant treatment effect, but
that could have been a result of the low doses
prescribed, 27 as in real-life it is the most
frequently used cDMARD. 28
The treatment of PsA is complicated by the
heterogeneous clinical manifestations, on which
cDMARDs are poorly effective, while bDMARDs
suppress both skin and joint disease, retard
radiographic progression, and are effective for
enthesitis, dactylitis and axial involvement.
References
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HHE 2018 | hospitalhealthcare.com
Therefore, up to 40% of PsA patients are treated
with bDMARDs in real-life, with etanercept,
directed towards tumour necrosis alpha (TNFa)
being the most frequently prescribed according
to a large epidemiological study. 28 Beyond TNFa
inhibitors, bDMARDs with other mechanisms of
action (targeting interleukin (IL)-17 and IL-12/23)
are effective and safe in PsA. Moreover, in the
past, small molecules, or medications inhibiting
intracellular signalling pathways (Janus kinase or
phosphodiesterase 4) have supplemented the
therapeutic armamentarium for PsA.
In addition to pharmacotherapy, patient
education and physical activity are crucial in
the management of PsA, in particular, lifestyle
modifications including smoking cessation,
weight reduction and stress management.
Finally, recommendation on the treat-to-target
strategy for PsA have been made, since it has been
demonstrated that a target-driven approach in
rheumatoid arthritis is superior to usual care for
clinical, functional and structural outcomes.
According to the most recent recommendations,
remission/inactive disease of musculoskeletal and
extra-articular manifestations should be the
treatment target; however low/minimal disease
activity might be an alternative target. It is
important therefore to measure disease activity
based on clinical signs and symptoms, as well as
acute phase reactants. We have numerous tools
to measure disease activity, of which some have
been specifically developed and validated for PsA.
In particular, for PsA, DAPSA (disease activity
index for psoriatic arthritis) and MDA (minimal
disease activity) should be considered to define
the target. 29
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27 Kingsley GH et al. A
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