Faculty M. Elaine Husni, MD, MPH Vice Chair, Rheumatology Director, Arthritis and Musculoskeletal Center Cleveland Clinic Assistant Professor Cleveland Clinic Lerner College of Medicine Case Western Reserve University Cleveland, Ohio Joseph F. Merola, MD, MMSc Assistant Professor, Harvard Medical School Director, Clinical Unit for Research Innovation and Trials (CUReIT) Director, Center for Skin and Related Musculoskeletal Diseases Associate Program Director, Harvard Combined Internal Medicine-Dermatology Residency Training Program Brigham and Women’s Hospital Boston, Massachusetts

Learning Objectives Describe the etiology and socioeconomic and psychosocial burden of PsA and the importance of early detection and treatment Incorporate classification criteria into assessment of suspected PsA cases Identify PsA-associated comorbidities, such as CVD, obesity, and IBD, as well as their implication on the choice of treatment options

Learning Objectives continued Increase clinician communication to minimize differences in the assessment of PsA-disease severity and to improve understanding of patient satisfaction with current treatment options Apply an integrated approach to therapeutic intervention, incorporating patient-centric evidence and best practice recommendations for each treatment domain of PsA Describe the mechanisms and latest safety and efficacy evidence for approved and emerging biologic and non-biologic DMARDs for the treatment of patients with PsA

Module 1: Prevalence and Burden of Disease; Importance of Early Screening and Classification Criteria In this module, we address the prevalence and psychosocial burden of psoriatic arthritis (PsA), as well as the ongoing clinical challenges of underdiagnosed patients suffering with PsA. We discuss the importance of early detection and will review available screening questionnaires that can help provide an earlier diagnosis.

Prevalence and Disease Burden of Psoriatic Arthritis Affects ~3.2 million in the United States Affects up to 42% of ~7.5 million in U.S. with psoriasis Affects men and women equally Sources: American Academy of Dermatology Work Group, Menter A, Korman NJ, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions. J Am Acad Dermatol. 2011;65(1):137-174. Gladman DD. Recent advances in understanding and managing psoriatic arthritis. (Version 1.) F1000Res. 2016; 5: 2670. doi: 10.12688/f1000research.9592.1. Eder L, Chandran V, Gladman DD. Gender-related differences in patients with psoriatic arthritis. Int J Clin Rheumatol. 2012;7(6):641-649. American Academy of Dermatology Work Group, et al. J Am Acad Dermatol. 2011;65:137-174.  Gladman DD. F1000Res. 2016; 5: 2670; Eder L, et al. Int J Clin Rheumatol. 2012;7(6):641-649;

Prevalence and Psychosocial Burden of PsA Manifestations of arthritis in majority of patients (~85%) may not emerge until several years following evidence of skin disease Peak age of onset between 30 and 55 years More than 30% of psoriasis patients will develop PsA More men present with axial disease and radiographic damage Women exhibit worse functional outcomes compared to men Psychological burden and worse quality of life [than patients with psoriasis alone] Chronic conditions of psoriasis and arthritis “affect both the skin and joints, and can result in both functional and cosmetic concerns.”—Husni, Merola, et al. 2017 Sources: American Academy of Dermatology Work Group, Menter A, Korman NJ, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions. J Am Acad Dermatol. 2011;65(1):137-174. Gladman DD. Recent advances in understanding and managing psoriatic arthritis. (Version 1.) F1000Res. 2016; 5: 2670. doi: 10.12688/f1000research.9592.1. Nas K, Capkin E, Dagli AZ, et al. Gender specific differences in patients with psoriatic arthritis. Mod Rheumatol. 2017;27(2):345-349. doi: 10.1080/14397595.2016.1193105. Eder L, Chandran V, Gladman DD. Gender-related differences in patients with psoriatic arthritis. Int J Clin Rheumatol. 2012;7(6):641-649. Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum. 2017 Dec;47(3):351-360. doi: 10.1016/j.semarthrit.2017.05.010. American Academy of Dermatology Work Group, et al. J Am Acad Dermatol. 2011;65:137-174.  Gladman DD. F1000Res. 2016; 5: 2670; Eder L, et al. Int J Clin Rheumatol. 2012;7(6):641-649; Nas K, et al. Mod Rheumatol. 2017;27:345-349; Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.

Disease Burden of PsA Higher risk of developing PsA with presence of scalp psoriasis, nail lesions, inverse/intertriginous disease, extent of psoriasis and specific genetic markers1–3  Most patients (40–60%) suffer progressive, erosive, and potentially deforming joint disease resulting in decreased quality of life, comorbidities, disabilities, and extra-articular manifestations3,4 Economic burden of underdiagnosed and undertreated PsA: ~$35.2 billion annual healthcare burden5 $10,754 per individual (2013 prices) annual indirect costs of work disability6 Sources: Gladman DD. Clinical Features and Diagnostic Considerations in Psoriatic Arthritis. Rheum Dis Clin North Am. 2015;41(4):569-579.  Dolcino M, Ottria A, Barbieri A, et al. Gene Expression Profiling in Peripheral Blood Cells and Synovial Membranes of Patients with Psoriatic Arthritis. PLoS One. 2015;10(6):e0128262.  Helliwell PS, Ruderman EM. Natural History, Prognosis, and Socioeconomic Aspects of Psoriatic Arthritis. Rheum Dis Clin North Am. 2015;41(4):581-591.  Eder L, Haddad A, Rosen CF, et al. The Incidence and Risk Factors for Psoriatic Arthritis in Patients With Psoriasis: A Prospective Cohort Study. Arthritis Rheumatol. 2016;68(4):915-923.  Feldman SR, Zhao Y, Shi L, Tran MH, Lu J. Economic and comorbidity burden among moderate-to-severe psoriasis patients with comorbid psoriatic arthritis. Arthritis Care Res. 2015;67(5):708-717. Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum. 2017 Dec;47(3):351-360. doi: 10.1016/j.semarthrit.2017.05.010.   1. Gladman DD. Rheum Dis Clin North Am. 2015;41(4):569-579; 2. Dolcino M, et al. PLoS One. 2015;10(6):e0128262. 3. Helliwell PS, et al. Rheum Dis Clin North Am. 2015;41(4):581-591; 4. Eder L, et al. Arthritis Rheumatol. 2016;68(4):915-923. 5. Feldman SR, et al. Arthritis Care Res. 2015;67(5):708-717.  6. Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.

Challenges with Underdiagnosed PsA MAPP study reports average delay in diagnosis of 5 years1 Diagnosis often missed due to low level of awareness by clinical training with failure to connect skin and joint symptoms, primarily PCPs and dermatologists2 Results in progressive joint damage, deformities, disabilities, and reduced quality of life3,4 Dermatologists play pivotal role in the diagnosis of PsA Skin manifestations typically present before joint signs and symptoms5  Failure to recognize connection between skin and joint symptoms6 Mease et al—41% of PsO patients with PsA were not previously diagnosed7 Even 6-month diagnostic delay of effective treatment results in long-term poor radiographic and functional outcomes, such as bone erosion2,8 Sources: Kavanaugh A, Helliwell P, Ritchlin CT. Psoriatic Arthritis and Burden of Disease: Patient Perspectives from the Population-Based Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) Survey. Rheumatol Ther. 2016;3:91-102. Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum. 2017 Dec;47(3):351-360. doi: 10.1016/j.semarthrit.2017.05.010. Philipose J, Deodhar A. Classification Criteria for Psoriatic Arthritis: CASPAR. The Journal of Musculoskeletal Medicine (Online). 2012. http://www.rheumatologynetwork.com/psoriatic-arthritis/classification-criteria-psoriatic-arthritis-caspar. Accessed March 27, 2018. Helliwell P, Coates L, Chandran V, et al. Qualifying unmet needs and improving standards of care in psoriatic arthritis. Arthritis Care Res (Hoboken). 2014;66(12):1759-1766. Gottlieb AB, Greb JE, Goldminz AM. Psoriasis Trends and Practice Gaps. Dermatol Clin. 2016;34(3):235-242.  van de Kerkhof PC, Reich K, Kavanaugh A, et al. Physician perspectives in the management of psoriasis and psoriatic arthritis: results from the population-based Multinational Assessment of Psoriasis and Psoriatic Arthritis survey. J Eur Acad Dermatol Venereol. 2015;29(10):2002-2010. Mease P, Gladman D, Papp K, 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):729–735. 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):1045-1050.  MAPP, Multinational Assessment of Psoriasis and Psoriatic Arthritis; PsO, psoriasis 1. Kavanaugh A, et al. Rheumatol Ther. 2016;3:91-102. 2. Husni ME, et al. Semin Arthritis Rheum. 2017:351-360; 3. Philipose J, et al. Journal of Musculoskeletal Medicine (Online). 2012; 4. Helliwell P, et al. Arthritis Care Res. 2014;66:1759-1766; 5. Gottlieb AB, et al. Dermatol Clin. 2016;34:235-242. 6. van de Kerkhof PC, et al. J Eur Acad Dermatol Venereol. 2015;29:2002-2010. 7. Haroon M, et al. Ann Rheum Dis. 2015;74:1045-1050. 

Importance of Early Detection and Treatment Early Diagnosis Assessment of Clinical Severity Appropriate Treatment

Importance of Early Detection and Treatment Delayed and misdiagnosis results in negative impact on Overall health outcomes Quality of life Mental health Early detection can lead to improved, appropriate, timely treatment Prompt diagnosis and treatment can improve overall clinical outcomes* Sources: Philipose J, Deodhar A. Classification Criteria for Psoriatic Arthritis: CASPAR. The Journal of Musculoskeletal Medicine (Online). 2012. http://www.rheumatologynetwork.com/psoriatic-arthritis/classification-criteria-psoriatic-arthritis-caspar. Accessed March 27, 2018. 59 60 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):1045-1050.  Initiating appropriate treatment is critical to preservation of peripheral joints and long-term patient function.* *Philipose J, et al. Journal of Musculoskeletal Medicine.. 2012. 3. Haroon M, et al. Ann Rheum Dis. 2015;74(6):1045-1050. 

Clinical Presentation of Psoriasis

Psoriasis Phenotypes n=3850 Merola JF, Li T, Li WQ, Cho E, Qureshi AA. Prevalence of psoriasis phenotypes among men and women in the USA. Clin Exp Dermatol. 2016;41(5):486-9. doi: 10.1111/ced.12805. Merola JF, et al. Clin Exp Dermatol. 2016;41:486-9.

Clinical Presentation of Psoriatic Arthritis Clinical presentation of PsA is complex and heterogeneous PsA manifestations may include Increased asymmetric and oligoarticular joint involvement Distal interphalangeal joint involvement Dactylitis Enthesitis Psoriatic skin lesions Nail changes, including pitting, ridging, and/or distal onycholysis Increased symptoms of stiffness, pain, fatigue, and anxiety Sources: Raychaudhuri SP, Wilken R, Sukhov AC, Raychaudhuri SK, Maverakis E. Management of psoriatic arthritis: Early diagnosis, monitoring of disease severity and cutting edge therapies. J Autoimmun. 2017;76:21-37. Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum. 2017 Dec;47(3):351-360. doi: 10.1016/j.semarthrit.2017.05.010. Raychaudhuri SP, et al. J Autoimmun. 2017;76:21-37; Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.

Clinical Presentation of PsA

Clinical Presentation of PsA Dactylitis

Enthesitis

Clinical Domains of PsA Peripheral arthritis Affects large joints  Axial disease Chronic inflammatory arthritis, involving spine and or sacroiliac joints Varies among 25% to 70% of patients with PsA Enthesitis Dactylitis Inflammation of an entire digit Skin Nail disease Comorbidities Sources: Coates LC, Kavanaugh A, Mease PJ, et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis 2015 Treatment Recommendations for Psoriatic Arthritis. Arthritis Rheumatol. 2016;68(5):1060-71. doi: 10.1002/art.39573. Ritchlin CT, Kavanaugh A, Gladman DD, et al. Treatment recommendations for psoriatic arthritis. Ann Rheum Dis. 2009;68(9):1387-1394.    Presentation and Symptoms Gladman DD. Clinical Features and Diagnostic Considerations in Psoriatic Arthritis. Rheum Dis Clin North Am. 2015;41(4):569-579.  Coates LC, et al. Arthritis Rheumatol. 2016;68:1060-71; Ritchlin CT, et al. Ann Rheum Dis. 2009;68:1387-1394; Gladman DD. Rheum Dis Clin North Am. 2015;41:569-579. 

Diagnostic Work-Up Currently no standardized diagnostic test for PsA: clinical diagnosis Diagnostic work-up for PsA is based on: Medical history Physical examination Blood tests Imaging Review measurable elements to assess disease severity Number of joints affected or amount of swelling Sources: Ritchlin CT, Kavanaugh A, Gladman DD, et al. Treatment recommendations for psoriatic arthritis. Ann Rheum Dis. 2009;68(9):1387-1394.  Eder L, Chandran V, Gladman DD. Gender-related differences in patients with psoriatic arthritis. Int J Clin Rheumatol. 2012;7(6):641-649.  Ritchlin CT, et al. Ann Rheum Dis. 2009;68:1387-1394; Eder L, et al. Int J Clin Rheumatol. 2012;7:641-649. 

CASPAR: Classification Criteria for PsA Requires presence of inflammatory arthritis (e.g., joint, spine, or enthesis) for accurate diagnosis Criteria highly specific (99%) for PsA Personal history of psoriasis (current or past) Family history of psoriasis Psoriatic nail dystrophy Negative rheumatoid factor test Dactylitis Radiographic evidence of juxta-articular bone formation Sources: Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum. 2017 Dec;47(3):351-360. doi: 10.1016/j.semarthrit.2017.05.010. Raychaudhuri SP, Wilken R, Sukhov AC, Raychaudhuri SK, Maverakis E. Management of psoriatic arthritis: Early diagnosis, monitoring of disease severity and cutting edge therapies. J Autoimmun. 2017;76:21-37.  Coates LC, Conaghan PG, Emery P, et al. Sensitivity and Specificity of the Classification of Psoriatic Arthritis Criteria in Early Psoriatic Arthritis. Arthritis & Rheumatism. 2012;64(10):3150-3155.  Philipose J, Deodhar A. Classification Criteria for Psoriatic Arthritis: CASPAR. The Journal of Musculoskeletal Medicine (Online). 2012. http://www.rheumatologynetwork.com/psoriatic-arthritis/classification-criteria-psoriatic-arthritis-caspar. Accessed March 27, 2018. CASPAR, ClASsification criteria for Psoriatic ARthritis Husni ME, et al. Semin Arthritis Rheum. 2017:351-360; Raychaudhuri SP, et al. J Autoimmun. 2017;76:21-37; Coates LC, et al. Arthritis & Rheumatism. 2012;64:3150-3155; Philipose J, et al. Rheumatologynetwork.com. 2012.

10 + joint diagram self-report PsA Screening Tools Number of Questions Sensitivity % or Range Specificity % or Range PEST Psoriasis Epidemiology Screening Tool 5 + joint diagram 0.28 to 0.77 97% sensitivity 0.37 to 0.98 79% specificity ToPAS 2 Toronto Psoriatic Arthritis Screen, Version 2 11 + pictures/diagram 86.8% sensitivity 93.1% specificity PASE Psoriasis Arthritis Screening and Evaluation 15 0.24 to 0.75 82% sensitivity 0.39 to 0.94 73% specificity PASQ Psoriasis and Arthritis Screening Questionnaire 10 + joint diagram self-report CONTEST, developed from combinations of questions from PASE, PEST, and TO PAS 38% to 86% 35% to 89% Sources: Karreman MC, Weel AEAM, van der Ven M, et al. Performance of screening tools for psoriatic arthritis: a cross-sectional study in primary care. Rheumatology (Oxford). 2017;56(4):597-602. doi: 10.1093/rheumatology/kew410. Mease PJ, Armstrong AW. Managing Patients with Psoriatic Disease: The Diagnosis and Pharmacologic Treatment of Psoriatic Arthritis in Patients with Psoriasis. Drugs. 2014;74:423–441. Ogdie A, Weiss P. The Epidemiology Psoriatic Arthritis. Rheumatic diseases clinics of North America. 2015;41(4):545-568. doi:10.1016/j.rdc.2015.07.001. Raychaudhuri SP, Wilken R, Sukhov AC, Raychaudhuri SK, Maverakis E. Management of psoriatic arthritis: Early diagnosis, monitoring of disease severity and cutting edge therapies. J Autoimmun. 2017;76:21-37. Raychaudhuri SP, et al. J Autoimmun. 2017;76:21-37; Karreman MC, et al. Rheumatology. 2017;56:597-602; Mease PJ. Drugs. 2014; doi 10.1007/s40265-014-0191-y; Ogdie A, et al. Rheumatic diseases clinics of North America. 2015;41:545-568

Activity Measures for PsA Disease Activity Assessment and Composite measures for PsA* MDA: Minimal disease activity CPDAI: Composite Psoriatic Disease Activity Index First composite measure of disease activity DAPSA: Disease Activity in Psoriatic Arthritis score PASDAS: PsA Disease Activity Score Reliable and holistic composite index to measure disease activity RAPID3: Routine Assessment of Patient Index Data 3 Source: Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum. 2017 Dec;47(3):351-360. doi: 10.1016/j.semarthrit.2017.05.010. *Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.

Minimal Disease Activity Minimal disease activity (MDA) 5 out of 7 of the following: TJC 1 SJC 1 PASI 1 or BSA 3% Patient pain VAS 15 Patient global activity VAS 20 HAQ 0.5 Tender entheseal points 1 Source: 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. doi: 10.1136/ard.2008.102053. TJC, tender joint count; SJC, swollen joint count; PASI: Psoriasis Area and Severity Index; BSA, body surface area; VAS: visual analog scale; HAQ: Health Assessment Questionnaire Coates LC, et al. Ann Rheum Dis. 2010;69:48-53.

Module 2: Comorbidities In this module, we will discuss common comorbidities and risk factors associated with psoriatic arthritis and implications to disease management.

Addressing Co-Morbidities Increased prevalence and incidence of CVD, diabetes, obesity, depression, and anxiety in patients with active PsA Comorbidities 50% of patients with PsA have at least 1 comorbidity Results in decreased quality of life Implications to disease management Review patient satisfaction with current treatment options Source: Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum. 2017 Dec;47(3):351-360. doi: 10.1016/j.semarthrit.2017.05.010. Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.

Comorbidities associated with PsA Patients with PsA have more comorbidities than the general population Greater risk for IBD in patients with psoriasis and PsA Higher risk for cardiovascular disease1, 2 Leading cause of death (20-56%) in patients with PsA1 Identify high-risk CVD patients who may need more aggressive intervention Higher risk for depression (than patients with psoriasis alone) Presence of comorbid depression may affect adherence to treatment Sources: Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum. 2017 Dec;47(3):351-360. doi: 10.1016/j.semarthrit.2017.05.010. Craven J. Increased Prevalence of Coronary Atherosclerosis in Psoriatic Arthritis. January 10, 2017. http://www.rheumatologyadvisor.com/spondyloarthritis/coronary-artery-disease-burden-increased-in-psoriatic-arthritis/article/630529/. Accessed March 28, 2018. IBD, inflammatory bowel diseases; CVD, cardiovascular disease 1. Husni ME, et al. Semin Arthritis Rheum. 2017:351-360; 2. Craven J. RheumatologyAdvisor.com. 2017.

Co-morbidities Associated with PsA Cardiovascular disease Inflammatory bowel disease Depression/Anxiety Kidney disease Diabetes Metabolic syndrome Eye disease Obesity Fatty Liver disease Osteoporosis Gout Source: Husni ME. Comorbidities in Psoriatic Arthritis. Rheum Dis Clin North Am. 2015;41(4):677-698.  Husni ME, et al. Semin Arthritis Rheum. 2017:351-360; Husni ME. Rheum Dis Clin North Am. 2015;41(4):677-698. 

Why Are Comorbidities Important to Recognize? Allows comprehensive evaluation and management of the patient, and manifestations of disease May affect choice of therapeutic agents CAD Risk benefit of anti-osteoblastic activity of NSAIDs need to be balanced by risk of CAD, exacerbation of HTN Goodson et al—Use of NSAIDs associated with reduced CV mortality (Trelle et al—doubling of risk of CVD with NSAIDs in general population) IBD May be exacerbated by NSAIDs (Sandborn WJ et al—not Celecoxib?) Not all anti TNFs efficacious or approved for IBD Uveitis: Monoclonal anti TNF > Receptor antagonists Sulfasalazine may have a role Sources: Goodson N, Brookhart A, Symmons D, Silman A, Solomon D. Non-steroidal anti-inflammatory drug use does not appear to be associated with increased cardiovascular mortality in patients with inflammatory polyarthritis: results from a primary care based inception cohort of patients. Ann Rheum Dis. 2009;68: 367–372. Trelle S, Reichenbach S, Wandel S, et al. Cardiovascular safety of non-steroidal anti- inflammatory drugs: network meta-analysis. BMJ. 2011; 342: c7086. CAD, coronary artery disease; CVD, cardiovascular disease; HTN, hypertension; IBD, inflammatory bowel disease; TNF, tumour necrosis factor Goodson N, et al. Ann Rheum Dis. 2009;68: 367–372; Trelle S, et al. BMJ. 2011; 342: c7086.

Cardiovascular Morbidity in PsA 3 large studies confirmed an increased CV morbidity in PsA, including: IHD, CHF, CVA, and PVD Varying study designs and differences in CV endpoints Broadly comparable with other chronic diseases, such as diabetes and RA PsA has an increase in death rate of 1.3 due to CVD compared with general population Sources: Ahlehoff O, Gislason GH, Charlot M, et al. Psoriasis is associated with clinically significant cardiovascular risk: a Danish nationwide cohort study. J Intern Med. 2011;270(2):147-57. doi: 10.1111/j.1365-2796.2010.02310.x. Gladman DD, Ang M, Su L, Tom BD, Schentag CT, Farewell VT. Cardiovascular morbidity in psoriatic arthritis. Ann Rheum Dis. 2009;68(7):1131-5. doi: 10.1136/ard.2008.094839. Han C, Robinson DW Jr, Hackett MV, Paramore LC, Fraeman KH, Bala MV. Cardiovascular disease and risk factors in patients with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. J Rheumatol. 2006;33(11):2167-72. Wong K, Gladman DD, Husted J, Long JA, Farewell VT. Mortality studies in psoriatic arthritis: results from a single outpatient clinic. I. Causes and risk of death. Arthritis Rheum. 1997;40(10):1868-72. IHD, ischaemic heart disease; CHF, Congestive heart failure; CVA, cerebro-vascular accident; PVD, peripheral vascular disease Ahlehoff O, et al. J Intern Med. 2011;270:147-57; Gladman DD, et al. Ann Rheum Dis. 2009;68:1131-5; Han C, et al. J Rheumatol. 2006;33:2167-72; Wong K, et al. Arthritis Rheum. 1997;40:1868-72.

Hepatic steatosis affects the likelihood of not achieving MDA: Fatty Liver Disease NAFLD was significantly associated with metabolic syndrome, obesity, and dyslipidemia Patients with PsA were more likely to have NAFLD than patients with Psoriasis but without PsA (OR 3.94; 95%CI: 1.07-14.46) Hepatic steatosis affects the likelihood of not achieving MDA: aHR 1.91 (1.04-3.38) Source: Di Minno MN, Peluso R, Iervolino S, et al. Hepatic steatosis, carotid plaques and achieving MDA in psoriatic arthritis patients starting TNF-α blockers treatment: a prospective study. Arthritis Res Ther. 2012;14(5):R211. doi: 10.1186/ar4049. HS, hepatic steatosis; MDA, minimum disease activity; NAFLD, non-alcoholic fatty liver disease Di Minno MN, et al. Arthritis Res Ther. 2012;14:R211.

Screening Considerations Cardiovascular Disease Check blood pressure, lipid panel Encourage smoking cessation Depression and Anxiety Ask about symptoms of depression and anxiety Diabetes Check fasting glucose or hemoglobin A1c Inflammatory Bowel Disease Ask about gastrointestinal symptoms in the ROS Liver and Kidney Disease Check LFTs, Cr, HBV/HCV serologies before starting therapy Malignancy Consider yearly or periodic skin check for patients with a history of UV light therapy Obesity Council patients on the benefits of weight loss Ophthalmic Disease Ask about ophthalmic symptoms in the ROS Source: Ogdie A, Schwartzman S, Husni ME. Recognizing and managing comorbidities in psoriatic arthritis. Curr Opin Rheumatol. 2015;27(2):118-26. doi: 10.1097/BOR.0000000000000152. ROS, review of symptoms; LFTs, liver function test; Cr, creatinine; HBV/HCV, hepatitis C virus/hepatitis C virus  Ogdie A, et al. Curr Opin Rheumatol. 2015;27:118-26.

Comorbidity NSAIDs Glucocorticoids HCQ Sulfasalazine Methotrexate Leflunomide Cyclosporine Etanercept Adalimumab Infliximab Certolizumab Golimumab Usekinumab Apremilast CV disease C ? Congestive heart failure Obesity Metabolic syndrome Diabetes Ulcerative colitis A OL Crohn’s disease Uveitis P† P Osteoporosis Malignancy Fatty liver disease Chronic kidney disease SM Depression Chronic hepatitis B* Chronic hepatitis C* ?/P HIV GRAPPA Considerations for Treatment of Patients With PsA and Concomitant Comorbidities Anti-IL17 CC? A Approved for primary therapy C Reason for caution OL Off-label use P Preferred therapy SM Requires special monitoring ? Data insufficient, concerns raised Source: Coates LC, Kavanaugh A, Mease PJ, et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis 2015 Treatment Recommendations for Psoriatic Arthritis. Arthritis Rheumatol. 2016;68(5):1060-71. doi: 10.1002/art.39573. *When treating patients with chronic infections that can affect the liver, consider consultation with providers having expertise in the area. † Corticosteroids used as preferred therapy for uveitis are most commonly given as topical and/or intraocular injections (IAIs) in preference to oral steroids. GRAPPA, Group for Research and Assessment of Psoriasis and Psoriatic Arthritis; NSAIDs, nonsteroidal anti-inflammatory drug;. HCQ, hydroxychloroquine; CV, cardiovascular disease; HIV, human immunodeficiency virus. Coates LC, et al. GRAPPA 2015 Treatment Recommendations for Psoriatic Arthritis. Arthritis Rheumatol. 2016;68:1060-71.

Module 3: Provider Interdisciplinary and Clinician-Patient Communication In this module, we emphasize the importance of interdisciplinary communication. We will discuss how to develop care models through clinician communication, a patient-centered approach to treatment strategy, as well as the significance of clinician-patient communication addressing adherence.

Source: Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum. 2017 Dec;47(3):351-360. doi: 10.1016/j.semarthrit.2017.05.010. Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.

Psoriasis & Psoriatic Arthritis Clinics Multicenter Advancement Network PPACMAN A non-profit organization The mission of PPACMAN is to nucleate PsO/PsA combined clinics and centers to advance a multilevel approach to psoriatic patients, increase disease awareness and accelerate management Develop networks and relationships between community-based centers: create local-regional derm-rheum and other clinical partnerships Provide toolkits for starting combined partnerships, EMR templates, screening efforts, etc. Research agenda www.ppacman.org “Patients seen during a combined clinic had their diagnosis revised in 46% of the cases and were more likely to be treated with an appropriate systemic therapy than before (25% vs 15% and 37% vs. 16%, respectively)”. —Velez NF et al. Arch Derm Res. 2012; 304(1):7-13. Source: Okhovat JP, Ogdie A, Reddy SM, Rosen CF, Scher JU, Merola JF. Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network Consortium (PPACMAN) Survey: Benefits and Challenges of Combined Rheumatology-dermatology Clinics. J Rheumatol. 2017;44(5):693-694. doi: 10.3899/jrheum.170148. Velez NF, Wei-Passanese EX, Husni ME, Mody EA, Qureshi AA. Management of psoriasis and psoriatic arthritis in a combined dermatology and rheumatology clinic. Arch Dermatol Res. 2012;304(1):7-13. doi: 10.1007/s00403-011-1172-6. EMR, electronic medical records Okhovat JP, et al. J Rheumatol. 2017;44:693-694; Velez NF, et al. Arch Dermatol Res. 2012;304:7-13.

The Power of Co-Management and Communication How to communicate with other providers Establish roles Improve communication between PCP and rheum, and when appropriate, dermatologist, and psychiatrist Referral to rheumatologist Referral to psychologist trained in pain, when appropriate Read each others’ notes Pick up phone to discuss co-management Source: Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum. 2017 Dec;47(3):351-360. doi: 10.1016/j.semarthrit.2017.05.010. Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.

Co-Management in Practice Shared decision making and treatment objectives improve outcomes Monitor treatment (across the disciplines) Communicate to help improve patient adherence to treatment Collaborative care essential to address needs of PsA patient Help to avoid rebound risk and non-adherence to therapy Utilize physician assistants and specialist nurse practitioners Sources: Ritchlin CT, Kavanaugh A, Gladman DD, et al. Treatment recommendations for psoriatic arthritis. Ann Rheum Dis. 2009;68(9):1387-1394.  Garrido-Cumbrera M, Hillmann O, Mahapatra R, et al. Improving the Management of Psoriatic Arthritis and Axial Spondyloarthritis: Roundtable Discussions with Healthcare Professionals and Patients. Rheumatol Ther. 2017; 4(2): 219–231. doi: 10.1007/s40744-017-0066-2. Ritchlin CT, et al. Ann Rheum Dis. 2009;68:1387-1394; Garrido-Cumbrera M, et al. Rheumatol Ther. 2017; 4:219–231.

Module 4: Therapeutic Management Patient-Centered Approach to Treatment In this module, we will focus on mechanism of action of approved biologic treatment options, as well as the latest safety and efficacy data. We will provide insights into improving patient adherence.

Updated Guideline Recommendations 2016 EULAR guideline updates Based on new pharmacological agents (approved since 2009) IL-17i IL-12/23i PDE-4i TNFi Focus on musculoskeletal manifestations See EULAR algorithm for sequential treatment strategies to optimize outcomes* Source: Gossec L, Smolen JS, Ramiro S, 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.  EULAR, European League against Rheumatic Diseases; PDE-4i, phosphodiesterase 4; TNFi, tumor necrosis factor-alpha inhibitors inhibitor *Gossec L, et al. Ann Rheum Dis. 2016;75(3):499-510. 

GRAPPA Recommendations Select therapy based on most severe element of patient’s disease1,2 Focus on achieving low disease activity for disease domains of PsA Optimize functional status Minimize complications Improve quality of life [Rheumatologists] Take a more active role educating PCPs Screen for comorbidities, including obesity, anxiety, depression, and skin cancer3  Monitor and adjust treatment regularly Sources: Coates LC, Kavanaugh A, Mease PJ, et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis 2015 Treatment Recommendations for Psoriatic Arthritis. Arthritis Rheumatol. 2016;68(5):1060-1071. Pappas S. PsA Treatment Guidelines Organized by Five Domains. 2016. http://www.rheumatologynetwork.com/psoriatic-arthritis/psa-treatment-guidelines-organized-five-domains. Accessed March 28, 2018. McKnight W. Updated GRAPPA PsA recommendations call for integrated approach to care. 2016. http://www.mdedge.com/rheumatologynews/article/105930/psoriatic-arthritis/updated-grappa-psa-recommendations-call. Accessed March 28, 2018.    GRAPPA, Group for Research and Assessment of Psoriasis and Psoriatic Arthritis 1. Coates LC, et al. Arthritis Rheumatol. 2016;68(5):1060-1071; 2. Pappas S. 2016. 3. McKnight W. Updated GRAPPA PsA recommendations. 2016.  

Patient-Centered Approach to Treatment Strategy Consider the whole patient, including skin, joints, and known comorbidities, as well as psycho-social issues Importance of patient involvement in decision-making T2T recs based on shared decision making [between patient and specialist] Clinicians should convey details of treatment options and side effects Provide clinician-to-patient education on the following: Etiology Trigger factors Treatment options and side effects Source: Garrido-Cumbrera M, Hillmann O, Mahapatra R, et al. Improving the Management of Psoriatic Arthritis and Axial Spondyloarthritis: Roundtable Discussions with Healthcare Professionals and Patients. Rheumatol Ther. 2017; 4(2): 219–231. doi: 10.1007/s40744-017-0066-2. T2T, treat to target Garrido-Cumbrera M, et al. Rheumatol Ther. 2017; 4(2): 219–231.

Established Treatment Options Early stages are often treated with established agents NSAIDs—often first-line treatment Corticosteroids Oral csDMARDs—often second-line treatment (e.g., sulfasalazine, leflunomide, hydroxychloroquine) Dependent on the following patient-related factors Disease domain Prognostic factors Associated comorbidities Switch to a TNFi or novel biologic agent is often warranted Severity of disease Patient’s treatment preference based on side effects, administration, frequency Sources: Coates LC, Kavanaugh A, Mease PJ, et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis 2015 Treatment Recommendations for Psoriatic Arthritis. Arthritis Rheumatol. 2016;68(5):1060-1071.    Gossec L, Smolen JS, Ramiro S, 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.  Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum. 2017 Dec;47(3):351-360. doi: 10.1016/j.semarthrit.2017.05.010. NSAIDs, nonsteroidal anti-inflammatory drugs; csDMARDs, conventional synthetic and targeted synthetic DMARDs; TNFi, tumor necrosis factor inhibitor Coates LC, et al. Arthritis Rheumatol. 2016;68(5):1060-1071; Gossec L, et al. Ann Rheum Dis. 2016;75(3):499-510; Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.

Current Evidence-Based Treatment Strategies Continued understanding immunopathogenesis of PsA led to development of novel agents Biologics block the action of cells and proteins that play a major role in developing psoriasis and psoriatic arthritis Administration route by subcutaneous injection or by IV infusion Source: National Psoriasis Foundation. Moderate to Severe Psoriasis and Psoriatic Arthritis: Biologic Drugs. Available at https://www.psoriasis.org/about-psoriasis/treatments/biologics. TNF-alpha, tumor necrosis factor-alpha National Psoriasis Foundation. Moderate to Severe Psoriasis and Psoriatic Arthritis: Biologic Drugs. Available at https://www.psoriasis.org/about-psoriasis/treatments/biologics.

(biosimilar approved 2016) Class Agent FDA approved for PsA Adverse Events Primary Outcome Pivotal Clinical Trials Trial Results TNF inhibitors   etanercept 2005 Similar efficacy and safety in clinical trials; decrease prevalence of depression and insomnia Blocking TNF-alpha production helps stop the inflammatory cycle of psoriatic disease. Significant efficacy: Improves peripheral arthritis, axial arthritis, enthesitis, dactylitis, skin and nails, and inhibits joint damage and radiographic progression adalimumab (biosimilar approved 2016) infliximab Improved QoL in patients failing DMARDs and other TNFis certolizumab 2013 golimumab 2017  GO-REVEAL Long-term golimumab safety/ efficacy in PsA was demonstrated through 5 years. IL-17 antagonists ixekizumab SAEs occurring 1.5-2.5%. Safety profile consistent with findings in patients with moderate-to-severe plaque psoriasis. Benefits patients those who failed TNFi. Improved PRO in physical function, QoL, itch score, and work productivity; Good skin coverage—not as robust joint coverage; efficacy and improvement in QoL in biologic-naïve patients SPIRIT-P2 study Significant and sustained (52 weeks), clinically meaningful improvements in disease activity and physical function; greater skin clearance of plaque psoriasis, and inhibition of structural damage progression2 secukinumab 2016 Consistent safety profile over long-term exposure, with no new safety signals identified.4 Inhibits radiographic progression; efficacious in patients regardless of concomitant methotrexate treatment, TNFi-naïve, or those who had an inadequate response to prior TNFi FUTURE 5, FUTURE 1, FUTURE 2, and FUTURE 3 Significant and sustained decrease in PsA activity; inhibition of radiographic progression; improved patient-reported outcomes and measures of quality of life3,4; significantly improved ACR20 at week 16 vs placebo.4 Sources: Kavanaugh A, McInnes IB, Mease P, et al. Clinical efficacy, radiographic and safety findings through 5 years of subcutaneous golimumab treatment in patients with active psoriatic arthritis: results from a long-term extension of a randomised, placebo-controlled trial (the GO-REVEAL study). Ann Rheum Dis. 2014;73(9):1689-94. doi: 10.1136/annrheumdis-2013-204902. Mease PJ, van der Heijde D, Ritchlin CT, et al. Ixekizumab, an interleukin-17A specific monoclonal antibody, for the treatment of biologic-naive patients with active psoriatic arthritis: results from the 24-week randomised, double-blind, placebo-controlled and active (adalimumab)-controlled period of the phase III trial SPIRIT-P1. Ann Rheum Dis. 2017;76(1):79-87. Mease PJ, McInnes IB. Secukinumab: A New Treatment Option for Psoriatic Arthritis. Rheumatol Ther. 2016;3(1):5-29.  Mease P, van der Heijde D, Landewé R, et al. Secukinumab improves active psoriatic arthritis symptoms and inhibits radiographic progression: primary results from the randomised, double-blind, phase III FUTURE 5 study. Ann Rheum Dis. 2018. pii: annrheumdis-2017-212687. doi: 10.1136/annrheumdis-2017-212687. [Epub ahead of print] Nash P, Mease PJ, McInnes IB, et al. Efficacy and safety of secukinumab administration by autoinjector in patients with psoriatic arthritis: results from a randomized, placebo-controlled trial (FUTURE 3). Arthritis Res Ther. 2018;20(1):47. doi: 10.1186/s13075-018-1551-x. TNFi-alpha, tumor necrosis factor-alpha inhibitor; QoL, quality of life 1. Kavanaugh A, et Ann Rheum Dis. 2014;73:1689-94; 2. Mease PJ, et al. Ann Rheum Dis. 2017;76:79-87; 3. Mease PJ, et al. Rheumatol Ther. 2016;3:5-29; 4. Mease P, et al. Ann Rheum Dis. 2018. pii: annrheumdis-2017-212687; 5. Nash P, et al. Arthritis Res Ther. 2018;20:47.

Pivotal Clinical Trials Class Agent FDA approved for PsA Adverse Events Primary Outcome Pivotal Clinical Trials Trial Results IL-12/23 antagonists ustekinumab   2013 Mild respiratory tract infections, nasopharyngitis, headache, and injection site reactions Inhibition of radiographic progression. Sustained improvements in efficacy and QoL in patients failing DMARDs and other TNFis PSUMMIT 1 and PSUMMIT 2 (phase 3) Enthetisis study showing superiority to TNFi resolving enthesitis IL-12/23; sustained and significantly less radiographic progression in treated cohorts1–3 PDE-4 inhibitor apremilast 2014 Gastrointestinal intolerance Increases intracellular levels of cAMP resulting in decreased levels of proinflammatory cytokines5; Improved QoL in patients failing DMARDs and other TNFis; close monitoring of hema or metabolic parameters not required6 PALACE 1 (phase 3); ACTIVE study (phase 3B) Improved signs and symptoms of PsA (based on ARC20 response) in patients treated at week 16, regardless of prior biologic therapy or concomitant DMARD use.7 Continuous improvements in enthesitis and dactylitis. Retrospective analysis (March 2018)8 JAK inhibitor tofacitinib 2017 Fever, chills, night sweats, stomach pain, loss of appetite, diarrhea, or weight loss Unique MoA for those who have not responded well to DMARDs and TNFis; Inhibits JAK1 and JAK3 at relevant doses; broad acting immune modulator with greater immune suppression and clinical efficacy.6 Oral Psoriatic Arthritis Trial (OPAL) BROADEN and OPAL BEYOND (phase 3) Significant improvement over placebo using HAQ-D1 scores and ACR20 response in patients with poor prior response to csDMARDs or to TNFis.9 T-cell inhibitor abatacept Headache, upper respiratory tract infection, nasopharyngitis, and nausea Increased ACR20 response; beneficial in musculoskeletal manifestations  PsA-I and PsA-II (phase 3) studies Significantly increased ACR20 response; beneficial in musculoskeletal manifestations and well tolerated; not to be administered with TNF antagonists; nor with other biologic RA therapy.10 Sources: Roberts J, O'Rielly DD, Rahman P. A review of ustekinumab in the treatment of psoriatic arthritis. Immunotherapy. 2018;10(5):361-372. doi: 10.2217/imt-2017-0149. Epub 2018 Feb 14. Kavanaugh A, Ritchlin CT, Rahman P, et al. Ustekinumab, an anti-IL-12/23 p40 monoclonal antibody, inhibits radiographic progression in patients with active psoriatic arthritis: results of an integrated analysis of radiographic data from the phase 3, multicentre, randomised, double-blind, placebo-controlled PSUMMIT-1 and PSUMMIT-2 trials. Ann Rheum Dis. 2014;73(6):1000-1006. Araujo EG, Englbrecht M, Hoepken S, Finzel S, Hueber AJ, Rech J, Schett G. Ustekinumab Is Superior to TNF Inhibitor Treatment in Resolving Enthesitis in PsA Patients with Active Enthesitis—Results from the Enthesial Clearance in Psoriatic Arthritis Study [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). http://acrabstracts.org/abstract/ustekinumab-is-superior-to-tnf-inhibitor-treatment-in-resolving-enthesitis-in-psa-patients-with-active-enthesitis-results-from-the-enthesial-clearance-in-psoriatic-arthritis-study/. Accessed January 18, 2018. Mease PJ, Kellner H, Morita A, et al. Efficacy and Safety Results from a Phase 2 Trial of Risankizumab, a Selective IL-23p19 Inhibitor, in Patients with Active Psoriatic Arthritis [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). http://acrabstracts.org/abstract/efficacy-and-safety-results-from-a-phase-2-trial-of-risankizumab-a-selective-il-23p19-inhibitor-in-patients-with-active-psoriatic-arthritis/. Accessed January 18, 2018. Elyoussfi S, Thomas BJ, Ciurtin C. Tailored treatment options for patients with psoriatic arthritis and psoriasis: review of established and new biologic and small molecule therapies. Rheumatol Int. 2016;36:603-612.  Ritchlin CT, Krueger JG. New therapies for psoriasis and psoriatic arthritis. Curr Opin Rheumatol. 2016;28(3):204-210.  vanaugh A, Mease PJ, Gomez-Reino JJ, et al. Treatment of psoriatic arthritis in a phase 3 randomised, placebo-controlled trial with apremilast, an oral phosphodiesterase 4 inhibitor. Ann Rheum Dis. 2014;73(6):1020-1026. Nash P, Ohson K, Walsh J, et al. Early and sustained efficacy with apremilast monotherapy in biological-naïve patients with psoriatic arthritis: a phase IIIB, randomised controlled trial (ACTIVE). Ann Rheum Dis. 2018. pii: annrheumdis-2017-211568. doi: 10.1136/annrheumdis-2017-211568. [Epub ahead of print] Henriques C. Phase 3 Trials Show Response to Xeljanz in People with Active Psoriatic Arthritis. Psoriasis News Today. 2016. https://psoriasisnewstoday.com/2016/12/08/pfizer-phase-3-opal-trials-show-xeljanz-benefits-psoriatic-arthritis-patients/. Accessed March 27, 2018.  Mease PJ, Gottlieb AB, van der Heijde D, et al. Efficacy and safety of abatacept, a T-cell modulator, in a randomised, double-blind, placebo-controlled, phase III study in psoriatic arthritis. Ann Rheum Dis. 2017;76(9):1550-1558. doi: 10.1136/annrheumdis-2016-210724.   cAMP, Cyclic adenosine monophosphate; JAK, Janus kinase inhibitors; QoL, quality of life 1. Roberts J, et al. Immunotherapy. 2018;10:361-372. 2. Kavanaugh A, et al. Ann Rheum Dis. 2014;73(6):1000-1006; 3. Araujo EG, et al. Arthritis Rheumatol. 2017; 69 (suppl 10); Mease PJ, et al. Arthritis Rheumatol. 2017; 69 (suppl 10); 5. Elyoussfi S, et al. Rheumatol Int. 2016;36:603-612. 6. Ritchlin CT, et al. Curr Opin Rheumatol. 2016;28:204-210; 7. vanaugh A, et al. Ann Rheum Dis. 2014;73:1020-1026; 8.. Nash P, et al. Ann Rheum Dis. 2018. pii: annrheumdis-2017-211568. 9. Henriques C. Psoriasis News Today. 2016. 10. Mease PJ, et al. Ann Rheum Dis. 2017;76:1550-1558.

Efficacy and Safety of Approved Biologics Common adverse events for biologic agents: Nasopharyngitis, headache, upper respiratory tract infection, and arthralgia Slight increase in rate of serious infection TNFi efficacy reported to be higher among patients with normal body weight compared to those who are overweight* Encourage patients to achieve and maintain a healthy bodyweight to achieve minimal disease activity IL-17 inhibitors do not seem to protect against flares of inflammatory bowel disease, a known risk in patients with PsA Source: 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):813-817. TNFi, tumor necrosis factor-alpha inhibitors; IL-17, Interleukin 17 *Eder L, et al. Ann Rheum Dis. 2015;74(5):813-817.

Optimal Treatment Selection Determine optimal treatment selection based on: Long-term safety data of biologics Contraindications Tolerability Efficacy Costs (biologics) Assess clinical severity Strategy of treatment order Treat to Target in psoriatic arthritis: Tight Control of PsA (TICOPA) study Initiate or maintain systemic therapy

Improving Patient Adherence MAPP survey results of patients with PsA1,2: 45% discontinued oral or biologic therapy due to issues with safety, tolerability, or a lack of efficacy 64% concerned about health risks with long-term therapy 90% expressed need for better therapies Improve clinician/patient communication Develop treatment plan3,4 Simple Iterative Incorporates patient’s comorbidities Sources: Kavanaugh A, Helliwell P, Ritchlin CT. Psoriatic Arthritis and Burden of Disease: Patient Perspectives from the Population-Based Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) Survey. Rheumatol Ther. 2016;3:91-102. Lebwohl M, Bachelez H, Barker J, et al. Patient perspectives in the management of psoriasis: results from the population-based Multinational Assessment of Psoriasis and Psoriatic Arthritis Survey. J Am Acad Dermatol. 2014;70(5):871-881.  Coates LC, Kavanaugh A, Mease PJ, et al. Group for Research and Assessment of Psoriasis and Psoriatic Arthritis 2015 Treatment Recommendations for Psoriatic Arthritis. Arthritis Rheumatol. 2016;68(5):1060-1071.  Pappas S. PsA Treatment Guidelines Organized by Five Domains. 2016. http://www.rheumatologynetwork.com/psoriatic-arthritis/psa-treatment-guidelines-organized-five-domains. Accessed March 28, 2018.  MAPP, Multinational Assessment of Psoriasis and Psoriatic Arthritis 1. Kavanaugh A, et al. Rheumatol Ther. 2016;3:91-102; 2. Lebwohl M, et al. J Am Acad Dermatol. 2014;70:871-881; 3. Coates LC, et al. Arthritis Rheumatol. 2016;68:1060-1071; 4. Pappas S. 2016. http://www.rheumatologynetwork.com/psoriatic-arthritis/psa-treatment-guidelines-organized-five-domains.

Patient-Reported Outcomes (PRO) RAPID3: Routine assessment of patient index data Patient-reported, composite index designed for feasibility in clinical care Core data set patient self-reported measures Physical function Pain Patient global estimate PsAID: Psoriatic Arthritis Impact of Disease questionnaire Two PsAID questionnaires developed with physical and psychological domains: Clinical practice (12 domains of health) Articular disease activity, severity of psoriasis, and presence of a coexisting fibromyalgia Clinical trials (9 domains) DLQI: Dermatology Life Quality Index—measures impact of dermatological disease Sources: Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum. 2017 Dec;47(3):351-360. doi: 10.1016/j.semarthrit.2017.05.010. Gossec L, de Wit M, Kiltz U, et al. A patient-derived and patient-reported outcome measure for assessing psoriatic arthritis: elaboration and preliminary validation of the Psoriatic Arthritis Impact of Disease (PsAID) questionnaire, a 13-country EULAR initiative. Ann Rheum Dis. 2014;73(6):1012-9. doi: 10.1136/annrheumdis-2014-205207. Coates LC, Tillett W, Shaddick G, Pincus T5, Kavanaugh A, Helliwell PS. Value of RAPID3 in patients with PsA: results from the TICOPA and LOPAS II databases. Arthritis Care Res (Hoboken). 2017. doi: 10.1002/acr.23460. PsA, psoriatic arthritis; RA, rheumatoid arthritis Husni ME, et al. Semin Arthritis Rheum. 2017:351-360; Gossec L, et al. Ann Rheum Dis. 2014;73:1012-9; Coates LC, et al. Arthritis Care Res. 2017.

Domains Most Impacted by PsA Patient-Reported Issues Pain Sleep disturbance Fatigue Coping Skin problems Anxiety Work and/or leisure activities Embarrassment and/or shame Functional capacity Social participation Discomfort Depression Source: Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum. 2017 Dec;47(3):351-360. doi: 10.1016/j.semarthrit.2017.05.010. Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.

Module 5: Therapeutic Management (Treat to Target) In this module, we review treatment objectives, including treat-to-target strategy and treatment management, which includes continued assessment of musculoskeletal disease, skin disease, and health‐related quality of life. We also share highlights from upcoming 2018 ACR guidelines, and review the latest data from emerging treatments. Coates LC, et al. Arthritis Rheumatol. 2018;70(3):345-355.

National Psoriasis Foundation Treat-to-Target: SKIN NPF T2T in psoriasis = Target response BSA ≤1% @ 3 months and q6 months (or “acceptable response” of BSA ≤3% at 3 months or 75% improvement from baseline) NPF, National Psoriasis Foundation; T2T, treat-to-target; BSA, body surface area

Minimal Disease Activity Minimal disease activity (MDA) 5 out of 7 of the following: TJC 1 SJC 1 PASI 1 or BSA 3% Patient pain VAS 15 Patient global activity VAS 20 HAQ 0.5 Tender entheseal points 1 Source: 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. doi: 10.1136/ard.2008.102053. TJC, tender joint count; SJC, swollen joint count; PASI: Psoriasis Area and Severity Index; BSA, body surface area; VAS: visual analog scale; HAQ: Health Assessment Questionnaire Coates LC, et al. Ann Rheum Dis. 2010;69:48-53.

DPSA Remission Criteria DAPSA: Disease Activity and Psoriatic Arthritis Score Validated treatment target in daily practice <4 is remission cutoff PASDAS, remission cutoff <1.9

Treatment Objective Treat-to-target strategy to optimize patient care Use quantitative measures (e.g., PASDAS) of disease activity to maximize achieving very low-disease activity or remission An integrated approach to therapeutic intervention Remission The absence of clinical and laboratory evidence of significant inflammation or minimal-disease activity Source: Coates L, Gladman D, Nash P, et al. SAT0462 Secukinumab provides sustained pasdas related low disease activity in psoriatic arthritis: 2 year results from the future 2 study. Annals of the Rheumatic Diseases. 2017;76:948-949. PASDAS, The Psoriatic Arthritis Disease Activity Score Coates L, et al. Ann Rheum Diseases. 2017;76:948-949.

Treatment Algorithms and Switching Tailor treatment for individual patients, taking into account… Disease activity and severity Prognostic factors Comorbidities Cardio-metabolic risk factors Treatment history Access to therapies Repeated evaluations Patient preference Incorporate assessment and management of psychological and physical concerns of patients Sources: Gossec L, Smolen JS, Ramiro S, 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. Merola JF, Lockshin B, Mody EA. Switching biologics in the treatment of psoriatic arthritis. Semin Arthritis Rheum. 2017;47(1):29-37. doi: 10.1016/j.semarthrit.2017.02.001. Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum. 2017 Dec;47(3):351-360. doi: 10.1016/j.semarthrit.2017.05.010. Gossec L, et al. Ann Rheum Dis. 2016;75(3):499-510; Merola JF, et al. Semin Arthritis Rheum. 2017;47:29-37. Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.

Take Aways for PsA Early diagnosis and early, aggressive treatment should aim to halt or minimize joint damage and clearing skin psoriasis Treat key clinical domains (i.e., arthritis, spondylitis, enthesitis, dactylitis, skin, and nail disease) Be aware of comorbidities and their implication to treatment approaches Collaborate with an interdisciplinary approach to screening and managing patients Apply treat-to-target strategies to improve patient outcomes Educate patients on range of available treatments and new options Help patients gain a better understanding of their condition and how to manage it Source: Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum. 2017 Dec;47(3):351-360. doi: 10.1016/j.semarthrit.2017.05.010. Earlier diagnosis and treatment improves overall clinical outcomes interdisciplinary team improve patient outcomes Evaluate and re-evaluate should be continuous Husni ME, et al. Semin Arthritis Rheum. 2017:351-360.