2. 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

3. 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

4. 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

5. 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.

6. 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):
Gladman DD. Recent advances in understanding and managing psoriatic arthritis. (Version 1.) F1000Res. 2016; 5: doi: /f1000research
Eder L, Chandran V, Gladman DD. Gender-related differences in patients with psoriatic arthritis. Int J Clin Rheumatol. 2012;7(6):
American Academy of Dermatology Work Group, et al. J Am Acad Dermatol. 2011;65:  
Gladman DD. F1000Res. 2016; 5: 2670; Eder L, et al. Int J Clin Rheumatol. 2012;7(6): ;

7. 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):
Gladman DD. Recent advances in understanding and managing psoriatic arthritis. (Version 1.) F1000Res. 2016; 5: doi: /f1000research
Nas K, Capkin E, Dagli AZ, et al. Gender specific differences in patients with psoriatic arthritis. Mod Rheumatol. 2017;27(2): doi: /
Eder L, Chandran V, Gladman DD. Gender-related differences in patients with psoriatic arthritis. Int J Clin Rheumatol. 2012;7(6):
Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum Dec;47(3): doi: /j.semarthrit
American Academy of Dermatology Work Group, et al. J Am Acad Dermatol. 2011;65:  
Gladman DD. F1000Res. 2016; 5: 2670; Eder L, et al. Int J Clin Rheumatol. 2012;7(6): ; Nas K, et al. Mod Rheumatol. 2017;27: ; Husni ME, et al. Semin Arthritis Rheum. 2017:

8. 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):  
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):e  
Helliwell PS, Ruderman EM. Natural History, Prognosis, and Socioeconomic Aspects of Psoriatic Arthritis. Rheum Dis Clin North Am. 2015;41(4):  
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):  
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):
Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum Dec;47(3): doi: /j.semarthrit  
1. Gladman DD. Rheum Dis Clin North Am. 2015;41(4): ; 2. Dolcino M, et al. PLoS One. 2015;10(6):e  3. Helliwell PS, et al. Rheum Dis Clin North Am. 2015;41(4): ; 4. Eder L, et al. Arthritis Rheumatol. 2016;68(4): Feldman SR, et al. Arthritis Care Res. 2015;67(5):   6. Husni ME, et al. Semin Arthritis Rheum. 2017:

9. 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:
Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum Dec;47(3): doi: /j.semarthrit
Philipose J, Deodhar A. Classification Criteria for Psoriatic Arthritis: CASPAR. The Journal of Musculoskeletal Medicine (Online) 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):
Gottlieb AB, Greb JE, Goldminz AM. Psoriasis Trends and Practice Gaps. Dermatol Clin. 2016;34(3):  
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):
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):  
MAPP, Multinational Assessment of Psoriasis and Psoriatic Arthritis; PsO, psoriasis
1. Kavanaugh A, et al. Rheumatol Ther. 2016;3: Husni ME, et al. Semin Arthritis Rheum. 2017: ; 3. Philipose J, et al. Journal of Musculoskeletal Medicine (Online). 2012; 4. Helliwell P, et al. Arthritis Care Res. 2014;66: ; 5. Gottlieb AB, et al. Dermatol Clin. 2016;34: van de Kerkhof PC, et al. J Eur Acad Dermatol Venereol. 2015;29: Haroon M, et al. Ann Rheum Dis. 2015;74:  

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

11. 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) 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):  
Initiating appropriate treatment is critical to preservation of peripheral joints and long-term patient function.*
*Philipose J, et al. Journal of Musculoskeletal Medicine Haroon M, et al. Ann Rheum Dis. 2015;74(6):  

12. Clinical Presentation of Psoriasis

13. 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): doi: /ced
Merola JF, et al. Clin Exp Dermatol. 2016;41:486-9.

15. 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 Dec;47(3): doi: /j.semarthrit
Raychaudhuri SP, et al. J Autoimmun. 2017;76:21-37; Husni ME, et al. Semin Arthritis Rheum. 2017:

16. Clinical Presentation of PsA

17. Clinical Presentation of PsA
Dactylitis

18. Enthesitis

19. 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): doi: /art
Ritchlin CT, Kavanaugh A, Gladman DD, et al. Treatment recommendations for psoriatic arthritis. Ann Rheum Dis. 2009;68(9):  
Presentation and Symptoms
Gladman DD. Clinical Features and Diagnostic Considerations in Psoriatic Arthritis. Rheum Dis Clin North Am. 2015;41(4):  
Coates LC, et al. Arthritis Rheumatol. 2016;68: ; Ritchlin CT, et al. Ann Rheum Dis. 2009;68: ; Gladman DD. Rheum Dis Clin North Am. 2015;41:  

20. 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):  
Eder L, Chandran V, Gladman DD. Gender-related differences in patients with psoriatic arthritis. Int J Clin Rheumatol. 2012;7(6):  
Ritchlin CT, et al. Ann Rheum Dis. 2009;68: ; Eder L, et al. Int J Clin Rheumatol. 2012;7:  

21. 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 Dec;47(3): doi: /j.semarthrit
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):  
Philipose J, Deodhar A. Classification Criteria for Psoriatic Arthritis: CASPAR. The Journal of Musculoskeletal Medicine (Online) Accessed March 27, 2018.
CASPAR, ClASsification criteria for Psoriatic ARthritis
Husni ME, et al. Semin Arthritis Rheum. 2017: ; Raychaudhuri SP, et al. J Autoimmun. 2017;76:21-37; Coates LC, et al. Arthritis & Rheumatism. 2012;64: ; Philipose J, et al. Rheumatologynetwork.com

22. 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): doi: /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): doi: /j.rdc
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: ; Mease PJ. Drugs. 2014; doi /s y; Ogdie A, et al. Rheumatic diseases clinics of North America. 2015;41:

23. 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 Dec;47(3): doi: /j.semarthrit
*Husni ME, et al. Semin Arthritis Rheum. 2017:

24. 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): doi: /ard
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.

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

26. 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 Dec;47(3): doi: /j.semarthrit
Husni ME, et al. Semin Arthritis Rheum. 2017:

27. 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 Dec;47(3): doi: /j.semarthrit
Craven J. Increased Prevalence of Coronary Atherosclerosis in Psoriatic Arthritis. January 10, Accessed March 28, 2018.
IBD, inflammatory bowel diseases; CVD, cardiovascular disease
1. Husni ME, et al. Semin Arthritis Rheum. 2017: ; 2. Craven J. RheumatologyAdvisor.com

28. 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):  
Husni ME, et al. Semin Arthritis Rheum. 2017: ; Husni ME. Rheum Dis Clin North Am. 2015;41(4):  

29. 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.

30. 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): doi: /j x.
Gladman DD, Ang M, Su L, Tom BD, Schentag CT, Farewell VT. Cardiovascular morbidity in psoriatic arthritis. Ann Rheum Dis. 2009;68(7): doi: /ard
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):
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):
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: ; Wong K, et al. Arthritis Rheum. 1997;40:

31. 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: )
Hepatic steatosis affects the likelihood of not achieving MDA:
aHR 1.91 ( )
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: /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.

32. 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): doi: /BOR
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:

33. 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): doi: /art
*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:

34. 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.

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

36. 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
“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): doi: /jrheum
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: /s
EMR, electronic medical records
Okhovat JP, et al. J Rheumatol. 2017;44: ; Velez NF, et al. Arch Dermatol Res. 2012;304:7-13.

37. 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 Dec;47(3): doi: /j.semarthrit
Husni ME, et al. Semin Arthritis Rheum. 2017:

38. 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):  
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: /s
Ritchlin CT, et al. Ann Rheum Dis. 2009;68: ; Garrido-Cumbrera M, et al. Rheumatol Ther. 2017; 4:219–231.

39. 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.

40. 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):  
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):  

41. 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):
Pappas S. PsA Treatment Guidelines Organized by Five Domains Accessed March 28, 2018.
McKnight W. Updated GRAPPA PsA recommendations call for integrated approach to care 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): ; 2. Pappas S McKnight W. Updated GRAPPA PsA recommendations  

42. 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: /s
T2T, treat to target
Garrido-Cumbrera M, et al. Rheumatol Ther. 2017; 4(2): 219–231.

43. 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):  
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):  
Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum Dec;47(3): doi: /j.semarthrit
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): ; Gossec L, et al. Ann Rheum Dis. 2016;75(3): ; Husni ME, et al. Semin Arthritis Rheum. 2017:

44. 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
TNF-alpha, tumor necrosis factor-alpha
National Psoriasis Foundation. Moderate to Severe Psoriasis and Psoriatic Arthritis: Biologic Drugs. Available at

45. (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 %. 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): doi: /annrheumdis
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 pii: annrheumdis doi: /annrheumdis [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: /s x.
TNFi-alpha, tumor necrosis factor-alpha inhibitor; QoL, quality of life
1. Kavanaugh A, et Ann Rheum Dis. 2014;73: ; 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 pii: annrheumdis ; 5. Nash P, et al. Arthritis Res Ther. 2018;20:47.

46. 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): doi: /imt 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):
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). 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). 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:  
Ritchlin CT, Krueger JG. New therapies for psoriasis and psoriatic arthritis. Curr Opin Rheumatol. 2016;28(3):  
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):
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 pii: annrheumdis doi: /annrheumdis [Epub ahead of print]
Henriques C. Phase 3 Trials Show Response to Xeljanz in People with Active Psoriatic Arthritis. Psoriasis News Today 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): doi: /annrheumdis
cAMP, Cyclic adenosine monophosphate; JAK, Janus kinase inhibitors; QoL, quality of life
1. Roberts J, et al. Immunotherapy. 2018;10: Kavanaugh A, et al. Ann Rheum Dis. 2014;73(6): ; 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: Ritchlin CT, et al. Curr Opin Rheumatol. 2016;28: ; 7. vanaugh A, et al. Ann Rheum Dis. 2014;73: ; 8.. Nash P, et al. Ann Rheum Dis pii: annrheumdis Henriques C. Psoriasis News Today Mease PJ, et al. Ann Rheum Dis. 2017;76:

47. 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):
TNFi, tumor necrosis factor-alpha inhibitors; IL-17, Interleukin 17
*Eder L, et al. Ann Rheum Dis. 2015;74(5):

48. 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

49. 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:
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):  
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):  
Pappas S. PsA Treatment Guidelines Organized by 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: ; 3. Coates LC, et al. Arthritis Rheumatol. 2016;68: ; 4. Pappas S

50. 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 Dec;47(3): doi: /j.semarthrit
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): doi: /annrheumdis
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) doi: /acr
PsA, psoriatic arthritis; RA, rheumatoid arthritis
Husni ME, et al. Semin Arthritis Rheum. 2017: ; Gossec L, et al. Ann Rheum Dis. 2014;73:1012-9; Coates LC, et al. Arthritis Care Res

51. 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 Dec;47(3): doi: /j.semarthrit
Husni ME, et al. Semin Arthritis Rheum. 2017:

52. 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):

53. National Psoriasis Foundation Treat-to-Target: SKIN
NPF T2T in psoriasis =
Target response BSA 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

54. 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): doi: /ard
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.

55. 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

56. 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:
PASDAS, The Psoriatic Arthritis Disease Activity Score
Coates L, et al. Ann Rheum Diseases. 2017;76:

57. 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):
Merola JF, Lockshin B, Mody EA. Switching biologics in the treatment of psoriatic arthritis. Semin Arthritis Rheum. 2017;47(1): doi: /j.semarthrit
Husni ME, Merola JF, Davin S. The psychosocial burden of psoriatic arthritis. Semin Arthritis Rheum Dec;47(3): doi: /j.semarthrit
Gossec L, et al. Ann Rheum Dis. 2016;75(3): ; Merola JF, et al. Semin Arthritis Rheum. 2017;47: Husni ME, et al. Semin Arthritis Rheum. 2017:

58. 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 Dec;47(3): doi: /j.semarthrit
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: