Using a Treat-to-Target Strategy

Welcome, everyone. I'm Dr. John Whyte, chief medical office at WebMD. Today, we're going to talk about psoriatic arthritis. It affects over a million people, 30% of people with psoriasis.

It's a type of inflammatory arthritis for which there's no cure. But there are effective treatments. But the first step is diagnosis. You've got to recognize the signs and symptoms. So helping me unpack it all are two experts.

Dr. Evan Siegel, he's an assistant professor of medicine at Georgetown University School of Medicine and partner of the Arthritis and Rheumatism Associates, and Dr. Jasvinder Singh. He's professor of medicine and epidemiology at the University of Alabama and a staff physician at the Birmingham VA. Doctors, thanks for joining me.

Glad to be here.

Thank you for having us.

So we know treatment is critical. And, as I mentioned, there are a lot more effective treatments today than even a few years ago. So Dr. Siegel, I want to start with you and help educate patients about this concept of treat-to-target. What does that mean and what does it involve?

Well, as you mentioned, we have so many more treatments now, so many more than, say, not only 10 years ago or 20 years, ago but even five years ago. So the idea is that we want to treat to a very low disease activity state. And we have several ways that we can do that. But we do want to think about treating to target in each of the different domains, meaning each of the different areas that can be problematic in psoriatic arthritis.

So we would like to get to a point where there is a body surface area of psoriasis of say less than 3% and even 1% is the National Psoriasis Foundation goal. 1% body surface area is the amount of psoriasis that can be covered by one palm of the patient's hand. We'd like to see less than one joint still active. We'd like to see less than one and enthesis, the point where tendon or ligament attaches to bone, that is still active. And we'd like to see the resolution of dactylitis, or the inflammation of an entire digit.

Dr. Singh, I want to ask you, are doctors treating it aggressively enough in terms of managing it to those targets?

So I think the doctors are treating it much more aggressively than they were perhaps a decade ago. And some of that is related to the fact that we now have several more effective treatments that can be used. If one fails, you can use another one. Patients are more aware. Physicians have all these armaments in the toolbox to use.

I still do think that many of us still have the ability to do better. And I think that stems from a lot of sources of where suboptimal treatment may still be occurring. There is always the knowledge gap that might exist in terms of translating what we think is a goal and then having a mutually acceptable goal.

For example, for most rheumatologists, disease remission may be the only goal they want to have in all their patients. However, some patients will choose to have low disease activity, which is slightly higher disease than remission, because they may choose to not have two medications but one medication. They may have their own concerns with regards to potential side effects, even though most of the drugs we're using are quite safe.

And then doctor Singh, are patients going to have to be on these medications for life? Sometimes with psoriasis, people only use them during flare-ups. Does it differ for psoriatic arthritis?

I think that for psoriatic arthritis, we do tend to think of these treatments as long-term, whether in the coming years we're going to have tapering trials where somebody has been in deep remission for at least a couple of years of tapering therapy when there are multiple medications. I think those are the sort of studies we need because the first question patient asks us when they have had no symptoms, no swollen, tender joint, skin disease under control, there is no enthesitis and no dactylitis, is how long do I have to be on this stock? And my answer is, well, we don't have a lot of good trials.

But I would like you to be in remission or very low disease activity for at least a couple of years before we can think about and have data of which of these medications can we back off. So some of this data are emerging since the publication of the guideline. And I think that in the next iteration of guideline, by then we should have a lot more trials looking into this.

I often say to patients that, unfortunately, this is not a curable disease as yet. So what we really are doing is suppressing disease activity, suppressing inflammation. And in general, when we take away the drug, the disease activity comes back.

As Dr. Singh said, I think there is emerging data on this. And eventually we may have a much better answer. There has been a push to being able to back off on these medications, of course, in part, because of their expense.

Every drug has risks and benefits. And some of the targeted therapies and biologics may depress the immune function, given that this is an autoimmune disease. How does that play into your consideration?

Well, it certainly does. And earlier in patients who have background disorders that may increase their likelihood of having infection, diabetes, chronic obstructive pulmonary disease, and others, then I really have to take that seriously into account. All of these medicines can suppress the immune system. And for the most part, all of them, that issue needs to be discussed with patients so that they know that if they are having an acute infectious process, if they're running a fever, that, more than anybody else, they need to make sure that they get in to medical care and bring that to attention because those infections can become severe quickly.

Having said that, there are some differences between the medicines. Some of them are more likely to be associated with infection. And we see a higher incidence of infection than others. So we do take that into account.

Certainly in this time of COVID, we think about that specifically. Most of the medicines that we are using for psoriatic arthritis specifically, don't particularly increase the risk of COVID infection.

Doctor Singh, is there a role for surgery as joints may become destroyed?

So that is what every rheumatologist wants to prevent. However, patients have gone on with severe disease before the advent of these very effective treatments. We don't have treatments that can reverse joint damage. And therefore, the focus of every rheumatologist is to be as aggressive in slowing down and delaying the progression. However, the subclinical inflammation and sometimes uncontrolled inflammation for a period of time can add to cumulative joint injury and joint damage. And as patients age, as well, they can also develop superimposed osteoarthritis and on top of damaged joints.

So a combination of long-term disease and previous damage, as well as concomitant osteoarthritis, will lead some of the large joints become eligible for total joint replacement. And, in fact, that is just as successful in terms of improving quality of life and improving function and reducing pain or eliminating pain as it would be in a patient with osteoarthritis with a bad knee or a bad hip or a bad shoulder. So those joints do tend to get replaced. And those are good treatments.

Dr. Singh, what do you tell the viewer who's come to WebMD, who recently has been diagnosed with psoriatic arthritis. What's your message to them?

I think what I'd like to say is that this is a serious disease. This is a disease that affects quality of life. It affects your social activities, your relationships. It's a very treatable disease. It's a very manageable disease with medications that have been around for a good 20-25 years.

We have plenty of data. So seek help early. Get treated. Get the disease under control.

I think one other thing is the gap in the way patients and providers may perceive psoriatic arthritis. We as rheumatologists take it very seriously because we are aware that how well we control this disease in the first two to three years is going to impact the 20-30 year downstream effects. And ongoing treatment and control also does that. But how we really handle the disease in the first 2-5 years has a very long-term impact on this.

What are we going to be talking about in terms of psoriatic arthritis? Will anything be different three years from now? Everybody wants to look at five years, 10 years. I just want to look at three. What's the story going to be there?

I think with the incredible progress in various different therapies that we have, I think we will have a number of additional therapies. There has been a push by the National Psoriasis Foundation to try to find a cure for this disease. I doubt that's going to be the case in three years. But who knows a decade from now what we will have.

We are understanding more and more about the pathophysiology of this disorder and how to interrupt that pathophysiology. So I think we are in the process of seeing more oral medications that are coming out. We are seeing more medications that are targeting different or slightly different cytokines. And that's only good news for patients because the more treatments we have, the more ability we have to treat people who didn't respond to one or another, so different than how we were treating this 30 years ago when there was really nothing available.

And as you both point out, the key is to get treated early and to get treated aggressively, to reach those targets. Gentlemen, I want to thank you both for joining me today and helping educate patients about their options and in terms of treatment of psoriatic arthritis.

Thank you.

My pleasure.

If you have any additional questions, please feel free to drop me a line. You can email me at [email protected]. Thanks for watching.

[MUSIC PLAYING]