Introduction
Psoriatic arthritis (PsA) and axial spondyloarthritis (AxSpA) are chronic, progressive, and often debilitating conditions with a substantial burden of disease. AxSpA, which includes both ankylosing spondylitis (AS) and non-radiographic AxSpA (nrAxSpA), is associated with progressively worsening pain and stiffness, impaired physical function, and in many patients, structural damage of the axial skeleton [
1]. PsA is associated with painful, stiff, and swollen joints, functional impairment, and if untreated, progressive structural damage of affected joints [
2]. The prevalence of AS ranges from 0.02% to 0.35% worldwide, whereas the prevalence of PsA ranges from 0.01% to 0.19% [
3] and can be up to approximately 40% in patients with psoriasis [
2]. Both conditions negatively affect quality of life, physical and social functioning, and work productivity, in addition to being associated with comorbidities and increased mortality [
4‐
9].
Pharmacologic treatment options for PsA and AxSpA include nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line treatment [
10‐
13]. Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) are recommended as second-line treatment for PsA; other options include biologic therapies, such as anti-tumor necrosis factor (anti-TNF) therapies (for PsA, nrAxSpA, and AS), anti-IL-17 therapy (for PsA and AS), and anti-IL-12/23 therapy (for PsA) [
10‐
13].
Although the introduction of biologic therapies has vastly improved clinical outcomes in patients with PsA and AxSpA, patient surveys indicate that many patients are still not receiving optimal treatment for their condition [
14‐
16]. Survey data collected by the National Psoriasis Foundation in the USA indicate that 45.5% of 1712 respondents with PsA expressed dissatisfaction with current therapies [
14]. From the 2012 Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) survey, 59% of patients with self-reported PsA were not receiving any systemic treatment for their PsA and were either on topical therapy only or receiving no treatment. Moreover, 46% of 1209 patients who had ever used oral therapies or biologic agents felt that using currently available therapies can be worse than the condition itself, and the majority of patients (85%) indicated that better therapies are needed [
15]. Indeed, a number of other limitations have been identified with anti-TNF therapies in the literature, which apply to both PsA and AxSpA, including the relatively high proportion of patients who do not respond well to these treatments and their failure to induce long-lasting remission [
17].
A treat-to-target (T2T) approach to therapy is defined by physicians aiming for specific, defined targets, and adjusting treatment accordingly until these targets are achieved. Adopting this approach in PsA and AxSpA may aid the definition, measurement, and achievement of treatment success. A T2T approach has proven successful in rheumatoid arthritis (RA) [
18], and with treatment advances now making such a strategy feasible in PsA and AxSpA, T2T recommendations in spondyloarthritis have been published by an international task force [
19]. These recommendations inform rheumatologists, other healthcare professionals, and patients about strategies to reach optimal outcomes based on evidence and expert opinion. The effectiveness of a T2T approach has already been demonstrated in PsA [
20] and is highlighted in both the European League Against Rheumatic Diseases (EULAR) recommendations for the management of PsA [
10] and the Assessment of SpondyloArthritis international Society (ASAS)-EULAR management recommendations for axial spondyloarthritis [
13].
As the impact of both PsA and AxSpA for patients is far-reaching, beyond simply musculoskeletal symptoms that are often the primary focus of most rheumatology guidelines, a patient-centered approach is imperative when developing recommendations or choosing suitable treatment targets [
21].
Patient involvement in decision-making is recognized as important in PsA and AxSpA [
19]. In the T2T recommendations, the first overarching principle emphasizes that the treatment target must be based on a shared decision between the patient and the rheumatologist [
19], which, to be implemented, requires effective communication between patients and physicians. This sentiment is also reflected in the fourth principle of the recent 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis [
13]. Although most potential treatment targets take into account the patient perspective through the inclusion of patient-reported outcomes, few patients have been involved in the development or setting of these targets to date.
Two roundtable discussions attended by representatives from 14 different patient advocacy groups from France, Ireland, Italy, Russia, Switzerland, Spain, and the UK alongside two expert physicians in rheumatology from The Netherlands and the UK, were held in February 2016. One meeting focused on PsA, while the other centered on AxSpA. Patient advocacy groups from across Europe were invited to participate, with the aim of gathering a broad range of perspectives from throughout the region. The two physicians were selected on the basis of their knowledge and expertise regarding the patient perspective in spondyloarthritis.
Both meetings took the format of a traditional roundtable discussion, with short presentations followed by free discussion. Presentations were themed on the burden of disease and on treatment targets from the perspectives of the physician and patient. The objectives of both meetings were to explore what patients consider to be important treatment targets, what they perceive as unmet needs, and whether patient-defined treatment goals were consistent with priority outcomes from the physicians’ perspective. Subsequently, a further virtual meeting was held involving attendees from both the PsA and AxSpA roundtable discussions, in order to consolidate the main outcomes of the two meetings. Outcomes were analyzed thematically, with no formal method of gathering consensus.
This discussion paper summarizes the key findings and proposals identified by the working group. This article is based on previously conducted studies and does not involve any new studies of human or animal subjects performed by any of the authors.
Discussion
The present discussion group of patient organization representatives and rheumatologists explored what patients with PsA and AxSpA consider to be important treatment targets and unmet needs. Key priorities comprised reducing time to diagnosis, increasing patient and physician disease knowledge and awareness, focusing on patients’ priorities for treatment goals, and improving patient–physician communication. Reducing pain and fatigue, and improving physical and social functioning and work productivity were identified as important treatment goals for patients.
Regarding therapeutic strategies, there is still a requirement for more T2T strategy trials in PsA to provide further supporting evidence for this approach alongside the tight control of inflammation in early psoriatic arthritis (TICOPA) trial [
20]. Although a similar strategy trial has commenced in AS (Tight Control in Spondyloarthritis [TICOSpA]; NCT03043846), there is currently no evidence for this approach in this condition. Optimal targets and treatment regimens for the T2T approach need to be based on evidence and further research is therefore required to decipher them; however, their selection must have appropriate patient involvement. Indeed, including patient perspectives and priorities in PsA and AxSpA disease management strategies is imperative to help meet patient expectations and improve satisfaction with treatment choices and strategies, ultimately improving patients’ long-term quality of life.
The current article is subject to some limitations. The outcomes presented are based on the opinions of individuals and may not necessarily be representative of the opinions of all patients with PsA or AxSpA. Nevertheless, attendees were invited from a variety of different patient advocacy groups to ensure that a wide range of opinions were collected. No formal method for gathering consensus was employed in the current article, with the key discussion topics being analyzed thematically. It is important, however, to acknowledge the added value of collecting qualitative information: gaining insights into patients’ thoughts and experiences can help ascertain potential avenues of investigation in larger quantitative studies [
79]. Large-scale surveys would be required to obtain a wider perspective from patients and physicians and allow a more quantitative analysis of the themes described herein. Finally, the purpose of this article was not to provide a systematic review of the literature and it should not be considered as such.
Acknowledgements
Novartis Pharma AG, Basel, Switzerland provided funding for the roundtable discussion and the article processing fees. All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval for the version to be published. All authors had full access to all of the data in this study and take complete responsibility for the integrity of the data and accuracy of the data analysis. We would like to thank Igor Steinzeig, Society of Patients with Psoriasis, Russia; Celia Marin, EUROPSO, Spain; Michelle Dolan, Irish Skin Foundation, Ireland; Pierre Charle, France Psoriasis, France; Renato Saviani, ATMaR Prato, Italy; Sara Severoni, ANMAR Italia, Italy; Pedro Plazuelo, CEADE, Spain; Pierre Faugère, AFLAR Association, France; Sally Dickinson, NASS, UK; and all patient organization representatives who also participated in the roundtable discussions. We would also like to thank Sanja Njegic, Head Patient Advocacy and Relations, Region Europe; Louise Huneault, Manager, Patient Relations, Global Communications and Advocacy; Emilie Prazakova, Patient Relations Manager, Region Europe; Angels Costa, Patient Advocacy Manager; Susanne O’Reilly, Government and External Affairs Head; Zhanna Baskakova, Scientific Medical Project Manager; Steffen Jugl, Worldwide Director Health Economics and Outcomes Research; Matteo Lacchio, Digital and Social Media Manager; Fabienne Porchet; Paralegal, Legal and Compliance, Region Europe; Chiara Perella, Associate Regional Medical Director, Immunology and Dermatology, Region Europe; participants of the roundtable discussion from Novartis Pharma AG; and finally Kathy Redmond, Redmond Consulting, Switzerland and Professor Dominique Baeten, Academic Medical Center/University of Amsterdam, The Netherlands, who also participated. Editorial assistance in the preparation of this manuscript was provided by Antonia Bowman and Molly Heitz, of Seren Communications, an Ashfield company, part of UDG Healthcare, the funding for which was provided by Novartis Pharma AG. We would also like to thank Alexey Sitalo, President of the Russian Ankylosing Spondylitis Association, for his review of the manuscript.