This article is part of the Topical Collection on Psoriatic Arthritis
Psoriatic arthritis (PsA) is a chronic inflammatory spondyloarthritis that can cause progressive joint damage and irreversible disability. Advances in modern therapies, now mean a target of remission is an achievable goal in PsA. There is strong and consistent evidence that a treat-to-target (T2T) approach to PsA management results in better patient outcomes; however, the practicalities of incorporating this strategy into routine clinical practice remain a challenge. The heterogeneous nature of this condition and the need for validated outcome measures have to-date hampered consensus on a definition of remission. This review aims to summarise the current T2T research landscape in PsA and highlight potential roles for biomarkers and imaging advances in revolutionising the T2T concept.
There is a growing body of evidence to support the implementation of a T2T strategy, using a pre-defined target in PsA management, with significant benefits in disease outcome, physical function and quality of life.
Whilst remission is the ultimately goal for PsA patients and their clinicians, further comparative studies of different treatment targets are needed to establish a widely acceptable definition of remission.
Mease PJ, Gladman DD, Papp KA, Khraishi MM, Thaçi D, Behrens F, et al. Prevalence of rheumatologist-diagnosed psoriatic arthritis in patients with psoriasis in European/North American dermatology clinics. J Am Acad Dermatol. 2013;69(5):729–35. CrossRef
Sokoll KB, Helliwell PS. Comparison of disability and quality of life in rheumatoid and psoriatic arthritis. J Rheumatol. 2001;28(8):1842–6. PubMed
Kane D, et al. A prospective, clinical and radiological study of early psoriatic arthritis: an early synovitis clinic experience. Rheumatology (Oxford). 2003;42(12):1460–8. CrossRef
Theander E, Husmark T, Alenius GM, Larsson PT, Teleman A, Geijer M, et al. Early psoriatic arthritis: short symptom duration, male gender and preserved physical functioning at presentation predict favourable outcome at 5-year follow-up. Results from the Swedish Early Psoriatic Arthritis Register (SwePsA). Ann Rheum Dis. 2014;73(2):407–13. CrossRef
Tillett W, Jadon D, Shaddick G, Cavill C, Korendowych E, de Vries CS, et al. Smoking and delay to diagnosis are associated with poorer functional outcome in psoriatic arthritis. Ann Rheum Dis. 2013;72(8):1358–61. CrossRef
Gladman DD, Thavaneswaran A, Chandran V, Cook RJ. Do patients with psoriatic arthritis who present early fare better than those presenting later in the disease? Ann Rheum Dis. 2011;70(12):2152–4. CrossRef
Haroon M, Gallagher P, FitzGerald O. Diagnostic delay of more than 6 months contributes to poor radiographic and functional outcome in psoriatic arthritis. Ann Rheum Dis. 2015;74(6):1045–50. CrossRef
Hansson L, Zanchetti A, Carruthers SG, Dahlöf B, Elmfeldt D, Julius S, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet. 1998;351(9118):1755–62. CrossRef
Nathan DM, et al. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977–86. CrossRef
Warram JH, Manson JE, Krolewski AS. Glycosylated hemoglobin and the risk of retinopathy in insulin-dependent diabetes mellitus. N Engl J Med. 1995;332(19):1305–6. CrossRef
Ridker PM. Moving toward new statin guidelines in a post-JUPITER world: principles to consider. Curr Atheroscler Rep. 2009;11(4):249–56. CrossRef
Grigor C, Capell H, Stirling A, McMahon AD, Lock P, Vallance R, et al. Effect of a treatment strategy of tight control for rheumatoid arthritis (the TICORA study): a single-blind randomised controlled trial. Lancet. 2004;364(9430):263–9. CrossRef
van Vollenhoven RF, Mosca M, Bertsias G, Isenberg D, Kuhn A, Lerstrøm K, et al. Treat-to-target in systemic lupus erythematosus: recommendations from an international task force. Ann Rheum Dis. 2014;73(6):958–67.
Kiltz U, Smolen J, Bardin T, Cohen Solal A, Dalbeth N, Doherty M, et al. Treat-to-target (T2T) recommendations for gout. Ann Rheum Dis. 2017;76(4):632–8. CrossRef
•• Coates LC, et al. Effect of tight control of inflammation in early psoriatic arthritis (TICOPA): a UK multicentre, open-label, randomised controlled trial. Lancet. 2015;386(10012):2489–98. The only trial addressing the comparison of a treat to target approach vs standard care in PsA. This trial demonstrated improved clinical and patient reported outcomes in a number of domains of disease.
Stenger AA, et al. Early effective suppression of inflammation in rheumatoid arthritis reduces radiographic progression. Br J Rheumatol. 1998;37(11):1157–63. CrossRef
Verstappen SM, et al. Intensive treatment with methotrexate in early rheumatoid arthritis: aiming for remission. Computer Assisted Management in Early Rheumatoid Arthritis (CAMERA, an open-label strategy trial). Ann Rheum Dis. 2007;66(11):1443–9. CrossRef
Fransen J, et al. Effectiveness of systematic monitoring of rheumatoid arthritis disease activity in daily practice: a multicentre, cluster randomised controlled trial. Ann Rheum Dis. 2005;64(9):1294–8. CrossRef
Vermeer M, Kievit W, Kuper HH, Braakman-Jansen LMA, Bernelot Moens HJ, Zijlstra TR, et al. Treating to the target of remission in early rheumatoid arthritis is cost-effective: results of the DREAM registry. BMC Musculoskelet Disord. 2013;14:350.
Schipper LG, Vermeer M, Kuper HH, Hoekstra MO, Haagsma CJ, Broeder AAD, et al. A tight control treatment strategy aiming for remission in early rheumatoid arthritis is more effective than usual care treatment in daily clinical practice: a study of two cohorts in the Dutch Rheumatoid Arthritis Monitoring registry. Ann Rheum Dis. 2012;71(6):845–50. CrossRef
van Eijk IC, Nielen MMJ, van der Horst-Bruinsma I, Tijhuis GJ, Boers M, Dijkmans BAC, et al. Aggressive therapy in patients with early arthritis results in similar outcome compared with conventional care: the STREAM randomized trial. Rheumatology (Oxford). 2012;51(4):686–94.
Soubrier M, Lukas C, Sibilia J, Fautrel B, Roux F, Gossec L, et al. Disease activity score-driven therapy versus routine care in patients with recent-onset active rheumatoid arthritis: data from the GUEPARD trial and ESPOIR cohort. Ann Rheum Dis. 2011;70(4):611–5. CrossRef
Goekoop-Ruiterman YP, et al. DAS-driven therapy versus routine care in patients with recent-onset active rheumatoid arthritis. Ann Rheum Dis. 2010;69(1):65–9. CrossRef
Cresswell L, Chandran V, Farewell VT, Gladman DD. Inflammation in an individual joint predicts damage to that joint in psoriatic arthritis. Ann Rheum Dis. 2011;70(2):305–8. CrossRef
Aletaha D, Alasti F, Smolen JS. Disease activity states of the DAPSA, a psoriatic arthritis specific instrument, are valid against functional status and structural progression. Ann Rheum Dis. 2017;76(2):418–21. CrossRef
Bond SJ, Farewell VT, Schentag CT, Gladman DD. Predictors for radiological damage in psoriatic arthritis: results from a single centre. Ann Rheum Dis. 2007;66(3):370–6. CrossRef
Coates LC, Fransen J, Helliwell PS. Defining minimal disease activity in psoriatic arthritis: a proposed objective target for treatment. Ann Rheum Dis. 2010;69(1):48–53. CrossRef
•• Coates LC, et al. Group for research and assessment of psoriasis and psoriatic arthritis/outcome measures in rheumatology consensus-based recommendations and research agenda for use of composite measures and treatment targets in psoriatic arthritis. Arthritis Rheumatol. 2018;70(3):345–55. This paper describes a consensus process led by the GRAPPA-OMERACT group to address the use of composite measures in PsA including potential targets of treatment. CrossRef
•• Gossec L, et al. European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update. Ann Rheum Dis. 2016;75(3):499–510. These are the current EULAR recommendations for the management of PsA.
•• Smolen JS, et al. Treating axial spondyloarthritis and peripheral spondyloarthritis, especially psoriatic arthritis, to target: 2017 update of recommendations by an international task force. Ann Rheum Dis. 2018;77(1):3–17. These are the current T2T recommendations in spondyloarthritis written by an international taskforce.
Kavanaugh A, Fransen J. Defining remission in psoriatic arthritis. Clin Exp Rheumatol. 2006;24(6 Suppl 43):S-83–7.
Caperon A, Helliwell PS. Remission in psoriatic arthritis. J Rheumatol Suppl. 2012;89:19–21. CrossRef
Coates LC, FitzGerald O, Gladman DD, McHugh N, Mease P, Strand V, et al. Reduced joint counts misclassify patients with oligoarticular psoriatic arthritis and miss significant numbers of patients with active disease. Arthritis Rheum. 2013;65(6):1504–9.
Mease PJ, Coates LC. Considerations for the definition of remission criteria in psoriatic arthritis. Semin Arthritis Rheum. 2017.
Schoels M, Aletaha D, Funovits J, Kavanaugh A, Baker D, Smolen JS. Application of the DAREA/DAPSA score for assessment of disease activity in psoriatic arthritis. Ann Rheum Dis. 2010;69(8):1441–7. CrossRef
Coates LC, Helliwell PS. Validation of minimal disease activity criteria for psoriatic arthritis using interventional trial data. Arthritis Care Res (Hoboken). 2010;62(7):965–9. CrossRef
Schoels MM, Aletaha D, Alasti F, Smolen JS. Disease activity in psoriatic arthritis (PsA): defining remission and treatment success using the DAPSA score. Ann Rheum Dis. 2016;75(5):811–8. CrossRef
Haddad A, Thavaneswaran A, Ruiz-Arruza I, Pellett F, Chandran V, Cook RJ, et al. Minimal disease activity and anti-tumor necrosis factor therapy in psoriatic arthritis. Arthritis Care Res (Hoboken). 2015;67(6):842–7. CrossRef
Mease PJ, Heckaman M, Kary S, Kupper H. Application and modifications of minimal disease activity measures for patients with psoriatic arthritis treated with adalimumab: subanalyses of ADEPT. J Rheumatol. 2013;40(5):647–52. CrossRef
Queiro R, et al. Minimal disease activity and impact of disease in psoriatic arthritis: a Spanish cross-sectional multicenter study. Arthritis Res Ther. 2017;19(1):72. CrossRef
Haugeberg G, Michelsen B, Tengesdal S, Hansen IJW, Diamantopoulos A, Kavanaugh A. Ten years of follow-up data in psoriatic arthritis: results based on standardized monitoring of patients in an ordinary outpatient clinic in southern Norway. Arthritis Res Ther. 2018;20(1):160. CrossRef
Salaffi F, et al. Disease activity in psoriatic arthritis: comparison of the discriminative capacity and construct validity of six composite indices in a real world. Biomed Res Int. 2014;2014:528105. CrossRef
van Mens LJJ, van de Sande MGH, van Kuijk AWR, Baeten D, Coates LC. Ideal target for psoriatic arthritis? Comparison of remission and low disease activity states in a real-life cohort. Ann Rheum Dis. 2018;77(2):251–7. CrossRef
van Mens LJJ, Turina MC, van de Sande MGH, Nurmohamed MT, van Kuijk AWR, Baeten DLP. Residual disease activity in psoriatic arthritis: discordance between the rheumatologist's opinion and minimal disease activity measurement. Rheumatology (Oxford). 2018;57(2):283–90. CrossRef
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):264–72. CrossRef
Michelsen B, et al. Discordance between tender and swollen joint count as well as patient’s and evaluator’s global assessment may reduce likelihood of remission in patients with rheumatoid arthritis and psoriatic arthritis: data from the prospective multicentre NOR-DMARD study. Ann Rheum Dis. 2017;76(4):708–11. CrossRef
Stamm TA, Nell V, Mathis M, Coenen M, Aletaha D, Cieza A, et al. Concepts important to patients with psoriatic arthritis are not adequately covered by standard measures of functioning. Arthritis Rheum. 2007;57(3):487–94. CrossRef
van Tuyl LH, et al. The patient perspective on remission in rheumatoid arthritis: ‘you’ve got limits, but you’re back to being you again’. Ann Rheum Dis. 2015;74(6):1004–10. CrossRef
Lubrano E, De Socio A, Perrotta FM. Comparison of composite indices tailored for psoriatic arthritis treated with csDMARD and bDMARD: a cross-sectional analysis of a longitudinal cohort. J Rheumatol. 2017;44(8):1159–64. CrossRef
•• van der Heijde D, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis. 2017;76(6):978–91. These are the current ASAS-EULAR recommendations for the management of axial spondyloarthritis which are relevant in the management of axial PsA.
Eder L, Thavaneswaran A, Chandran V, Cook RJ, Gladman DD. Obesity is associated with a lower probability of achieving sustained minimal disease activity state among patients with psoriatic arthritis. Ann Rheum Dis. 2015;74(5):813–7. CrossRef
Husted JA, Thavaneswaran A, Chandran V, Gladman DD. Incremental effects of comorbidity on quality of life in patients with psoriatic arthritis. J Rheumatol. 2013;40(8):1349–56. CrossRef
Helliwell P, Coates L, Chandran V, Gladman D, de Wit M, FitzGerald O, et al. Qualifying unmet needs and improving standards of care in psoriatic arthritis. Arthritis Care Res (Hoboken). 2014;66(12):1759–66. CrossRef
Coates LC, Helliwell PS. Treating to target in psoriatic arthritis: how to implement in clinical practice. Ann Rheum Dis. 2016;75(4):640–3. CrossRef
Gladman DD, Poulin Y, Adams K, Bourcier M, Barac S, Barber K, et al. Treating psoriasis and psoriatic arthritis: position paper on applying the treat-to-target concept to Canadian daily practice. J Rheumatol. 2017;44(4):519–34. CrossRef
Huscher D, Merkesdal S, Thiele K, Zeidler H, Schneider M, Zink A, et al. Cost of illness in rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and systemic lupus erythematosus in Germany. Ann Rheum Dis. 2006;65(9):1175–83. CrossRef
Bojke L, et al. Modelling the cost-effectiveness of biologic treatments for psoriatic arthritis. Rheumatology (Oxford). 2011;50(Suppl 4):iv39–47. CrossRef
Poole CD, Lebmeier M, Ara R, Rafia R, Currie CJ. Estimation of health care costs as a function of disease severity in people with psoriatic arthritis in the UK. Rheumatology (Oxford). 2010;49(10):1949–56. CrossRef
Brodszky V, Bálint P, Géher P, Hodinka L, Horváth G, Koó É, et al. Disease burden of psoriatic arthritis compared to rheumatoid arthritis, Hungarian experiment. Rheumatol Int. 2009;30(2):199–205. CrossRef
Greenberg JD, Palmer JB, Li Y, Herrera V, Tsang Y, Liao M. Healthcare resource use and direct costs in patients with ankylosing spondylitis and psoriatic arthritis in a large US cohort. J Rheumatol. 2016;43(1):88–96. CrossRef
O'Dwyer JL, Meads DM, Hulme CT, Mcparland L, Brown S, Coates LC, et al. Cost-effectiveness of tight control of inflammation in early psoriatic arthritis: economic analysis of a multicenter randomized controlled trial. Arthritis Care Res (Hoboken). 2018;70(3):462–8. CrossRef
Durham LE, Kirkham BW, Taams LS. Contribution of the IL-17 pathway to psoriasis and psoriatic arthritis. Curr Rheumatol Reports. 2015;17:55. CrossRef
Menon B, Gullick NJ, Walter GJ, Rajasekhar M, Garrood T, Evans HG, et al. Interleukin-17+CD8+ T cells are enriched in the joints of patients with psoriatic arthritis and correlate with disease activity and joint damage progression. Arthritis Rheumatol. 2014;66(5):1272–81. CrossRef
Res PC, et al. Overrepresentation of IL-17A and IL-22 producing CD8 T cells in lesional skin suggests their involvement in the pathogenesis of psoriasis. PLoS One. 2010;5(11):e14108. CrossRef
Ortega C, Fernández-A S, Carrillo JM, Romero P, Molina IJ, Moreno JC, et al. IL-17-producing CD8+ T lymphocytes from psoriasis skin plaques are cytotoxic effector cells that secrete Th17-related cytokines. J Leukoc Biol. 2009;86(2):435–43. CrossRef
Villanova F, Di Meglio P, Nestle FO. Biomarkers in psoriasis and psoriatic arthritis. Ann Rheum Dis. 2013;72(Suppl 2):ii104–10. CrossRef
Di Meglio P, Perera GK, Nestle FO. The multitasking organ: recent insights into skin immune function. Immunity. 2011;35(6):857–69. CrossRef
Maeda S, et al. The Th17/IL-23 axis and natural immunity in psoriatic arthritis. Int J Rheumatol. 2012;2012:539683. CrossRef
Chandran V, Cook RJ, Edwin J, Shen H, Pellett FJ, Shanmugarajah S, et al. Soluble biomarkers differentiate patients with psoriatic arthritis from those with psoriasis without arthritis. Rheumatology (Oxford). 2010;49(7):1399–405. CrossRef
Dalbeth N, Pool B, Smith T, Callon KE, Lobo M, Taylor WJ, et al. Circulating mediators of bone remodeling in psoriatic arthritis: implications for disordered osteoclastogenesis and bone erosion. Arthritis Res Ther. 2010;12(4):R164. CrossRef
Jadon DR, Sengupta R, Nightingale A, Lu H, Dunphy J, Green A, et al. Serum bone-turnover biomarkers are associated with the occurrence of peripheral and axial arthritis in psoriatic disease: a prospective cross-sectional comparative study. Arthritis Res Ther. 2017;19(1):210.
Freeston JE, Coates LC, Nam JL, Moverley AR, Hensor EMA, Wakefield RJ, et al. Is there subclinical synovitis in early psoriatic arthritis? A clinical comparison with gray-scale and power Doppler ultrasound. Arthritis Care Res (Hoboken). 2014;66(3):432–9. CrossRef
Balint PV, et al. Ultrasonography of entheseal insertions in the lower limb in spondyloarthropathy. Ann Rheum Dis. 2002;61(10):905–10. CrossRef
Gutierrez M, et al. A sonographic spectrum of psoriatic arthritis: “the five targets”. Clin Rheumatol. 2010;29(2):133–42. CrossRef
Wiell C, Szkudlarek M, Hasselquist M, Møller JM, Vestergaard A, Nørregaard J, et al. Ultrasonography, magnetic resonance imaging, radiography, and clinical assessment of inflammatory and destructive changes in fingers and toes of patients with psoriatic arthritis. Arthritis Res Ther. 2007;9(6):R119. CrossRef
De Simone C, et al. Usefulness of ultrasound imaging in detecting psoriatic arthritis of fingers and toes in patients with psoriasis. Clin Dev Immunol. 2011;2011:390726. CrossRef
Sankowski AJ, et al. The comparison of efficacy of different imaging techniques (conventional radiography, ultrasonography, magnetic resonance) in assessment of wrist joints and metacarpophalangeal joints in patients with psoriatic arthritis. Pol J Radiol. 2013;78(1):18–29. CrossRef
Polachek A, Cook R, Chandran V, Gladman DD, Eder L. The association between sonographic enthesitis and radiographic damage in psoriatic arthritis. Arthritis Res Ther. 2017;19(1):189. CrossRef
El Miedany Y, et al. Tailored approach to early psoriatic arthritis patients: clinical and ultrasonographic predictors for structural joint damage. Clin Rheumatol. 2015;34(2):307–13. CrossRef
Mandl P, Navarro-Compán V, Terslev L, Aegerter P, van der Heijde D, D'Agostino MA, et al. EULAR recommendations for the use of imaging in the diagnosis and management of spondyloarthritis in clinical practice. Ann Rheum Dis. 2015;74(7):1327–39. CrossRef
• Haavardsholm EA, et al. Ultrasound in management of rheumatoid arthritis: ARCTIC randomised controlled strategy trial. Bmj. 2016;354:i4205. This was one of the two studies addressing whether a T2T approach using ultrasound evaluation of disease activity in rheumatoid arthritis was superior to clinical assessment alone. This study was negative suggesting that clinical assessment of remission is sufficient to maximise patient response.
• Dale J, et al. Targeting ultrasound remission in early rheumatoid arthritis: the results of the TaSER study, a randomised clinical trial. Ann Rheum Dis. 2016;75(6):1043–50. This is the second study in rheumatoid arthritis evaluating ultrasound T2T which was also negative. CrossRef
Saleem B, Brown AK, Quinn M, Karim Z, Hensor EMA, Conaghan P, et al. Can flare be predicted in DMARD treated RA patients in remission, and is it important? A cohort study. Ann Rheum Dis. 2012;71(8):1316–21. CrossRef
Brown AK, Conaghan PG, Karim Z, Quinn MA, Ikeda K, Peterfy CG, et al. An explanation for the apparent dissociation between clinical remission and continued structural deterioration in rheumatoid arthritis. Arthritis Rheum. 2008;58(10):2958–67. CrossRef
Scire CA, et al. Ultrasonographic evaluation of joint involvement in early rheumatoid arthritis in clinical remission: power Doppler signal predicts short-term relapse. Rheumatology (Oxford). 2009;48(9):1092–7.s. CrossRef
- Novel Concepts in Psoriatic Arthritis Management: Can We Treat to Target?
Laura J. Tucker
Laura C. Coates
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