Should we treat psoriatic arthritis more aggressively?
Psoriatic arthritis patients under aggressive treatment were more likely to see significant improvement of their symptoms than patients on a standard treatment schedule, according to a recent.
At the end of the 48-week trial, 38 percent of patients under the aggressive treatment plan had experienced at least a 70 percent relief of symptoms; only 17 percent experienced a similar amount of relief while undergoing a standard level of care.
The study, performed in the United Kingdom, compared patients on a standard treatment schedule with patients on a treatment schedule that had doctors assessing symptoms more frequently and prescribing more aggressive treatment if patients did not experience significant relief from joint pain and stiffness. The findings were presented in October at the annual meeting of the American College of Rheumatology in San Diego by Dr. Laura Coates, a clinical lecturer at the Leeds Musculoskeletal Biomedical Research Unit of the National Institute for Health Research in the U.K.
All patients began treatment with methotrexate. Those under a so-called "treat-to-target" drug regimen were evaluated every four weeks according to set criteria, which included how many of their joints were swollen. If no more than one of the patient's joints or tendons remained affected, the methotrexate was considered on target and continued. If more were affected, doctors added sulfasalizine and patients were assessed again after four weeks. Every four weeks, if a patient's symptoms did not meet the standards of the study's criteria, the treat-to-target patient was advanced to a more aggressive treatment.
"I was very excited about this study," said Dr. Alexis Ogdie, assistant professor of medicine and epidemiology for University of Pennsylvania's rheumatology center. "This is one of the first trials to help us better understand how frequent follow-ups and tweaks in medications can make patients better."
Under standard care in the U.K., patients see their doctors every 12 weeks, and the decision whether to continue or to escalate treatment is simply the doctor's call.
"Usually we just ask how patients are doing," Coates said.
Doctors treating rheumatoid arthritis already use a treat-to-target"approach in the United States and the U.K.
Establishing that kind of approach with psoriatic arthritis will require follow-up, Ogdie said.
"One of the most important things is to understand whether treating people aggressively like this actually decreases the risk of deformities and permanent joint damage," Ogdie said, adding that the 48 weeks of the study was insufficient to establish this.
The study considered whether a more aggressive treatment regimen increased the frequency of adverse events because all of the drug treatments have the effect of suppressing a person's immunity to infection. Considered case by case, Coates said, only three out of 100 patients developed serious infections that might have been the result of aggressive therapy. By comparison, two patients under standard care suffered serious infections.